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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

April 2018

New Bunionectomy Medical Review Criteria

Effective June 1, 2018, Harvard Pilgrim is requiring prior authorization for bunionectomy procedures for our commercial members.

Harvard Pilgrim considers bunionectomy procedures medically necessary, with prior authorization, for the treatment of hallux valgus (bunions) when documentation confirms that the member has reached skeletal maturity and symptoms are unresponsive to at least 6 months of any two of the following conservative treatments:

  • Change in footwear, padding, or orthotics (shoe inserts) 
  • Nonsteroidal anti-inflammatory drugs
  • Local injections to the first metatarsophalangeal joint (e.g., local anesthetic or steroid)

In addition to the above-mentioned general bunionectomy criteria, the new prior authorization policy also outlines the criteria that must be met for the following specific procedures to be covered:

  • Simple bunionectomy
  • Bony correction bunionectomy
  • Surgical procedures for bunionettes

To request prior authorization, please complete the Bunionectomy Prior Authorization Request Form, and fax it to 800-232-0816. For complete information, please refer to Harvard Pilgrim’s new Bunionectomy Medical Review Criteria.

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    Eric H. Schultz,
    President and Chief Executive Officer

    Robert Farias,
    Senior Vice President, Corporate Network Strategy

    Annmarie Dadoly,

    Joseph O'Riordan,

    Kristin Edmonston,
    Production Coordinator