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

July 2018

Update to Harvard Pilgrim’s Gynecomastia Medical Review Criteria


Harvard Pilgrim is updating our commercial prior authorization policy for gynecomastia surgery to include additional criteria that must be met for the surgery to be considered medically necessary, effective for dates of service beginning Sept. 1, 2018.

In addition to the other criteria outlined in the policy, to be covered for gynecomastia surgery, members who have not been diagnosed with Klinefelter’s syndrome must be experiencing tenderness or pain in the breast tissue that persists despite a three-month trial of analgesic or non-steroidal anti-inflammatory drugs.
 
As a reminder, prior authorization is required for coverage of gynecomastia surgery. For complete criteria and coverage exclusions, please refer to Harvard Pilgrim’s updated Gynecomastia Surgery Medical Review Criteria.

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PUBLICATION INFORMATION

Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator