Harvard Pilgrim Health Care Home
  Learn more.
  Sign up for HPHConnect.
Medical Management
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Office Support
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
Print    Text Size

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

August 2015

New Clinical Medical Policies 

Harvard Pilgrim publishes medical policies to provide guidance on medically necessary interventions, and recently introduced the following clinical policies:

  • Entyvio (vedolizumab) — This medical policy documents when Harvard Pilgrim considers the use of the injectable medication Entyvio medically necessary in treating moderately to severely active Crohn’s disease or ulcerative colitis.

  • Proton beam therapy — Harvard Pilgrim considers this type of radiation therapy — which uses streams of protons to kill tumor cells without damaging nearby tissues — medically necessary for medulloblastoma; skull-based tumors (Chordomas and Chondrosarcomas) with no evidence of metastasis; uveal melanomas with no evidence of metastatis; and as initial monotherapy for prostate cancer when the cancer is localized.

  • Intensity Modulated Radiation Therapy (IMRT) — IMRT is an extension of three-dimensional conformal radiation therapy (3D-CRT) that changes the intensity of radiation in different parts of a single radiation beam while treatment is delivered. This therapy allows for an increased dose of radiation to the targeted area while reducing exposure to the surrounding normal tissue. Harvard Pilgrim considers IMRT to be medically necessary for the following conditions: cancers of the anus/anal canal; cancers of the abdomen and pelvis when the tumor is in close proximity to organs at risk; vulvar malignancies; prostate cancer; cancers of the breast and lung; cancers of the head and neck, including thyroid and esophagus; cancers of the central nervous system with close proximity to the optic nerve, lens, retina, optic chiasm, cochlea, or brain stem; and where critical structures cannot be adequately protected with standard 3-D CRT.

None of these policies are introducing changes to our current coverage, but are for purposes of clarification. For more information, please visit the Clinical Medical Policy section of the provider website.

Email this article to a colleague   

Network Matters Archives

Download printer-friendly version


ICD-10 Transition & Paper Claims Submission


New Clinical Medical Policies

Medical Criteria for Inverted Nipple Repair

The Safe Storage and Disposal of Opioids

New HEDIS Measure:  Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)

Prior Authorization Required for Duexis and Vimovo

Prior Authorization Required for Entresto

ICORE Healthcare Becoming Magellan Rx Pharmacy, LLC

Coordination of Care for Transgender Patients

Harvard Pilgrim’s EatRight Rewards Promotes Wellness


Bilateral Reimbursement

Update Coming to HPHConnect for Providers

Reminder: Save Time and Paper with Harvard Pilgrim’s Electronic Tools


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator