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Medicare Advantage Medical Necessity Guidelines

Harvard Pilgrim uses written criteria based on sound clinical evidence to evaluate the medical appropriateness of health care services. Our StrideSM (HMO/HMO-POS) Medicare Advantage medical necessity guidelines/authorization policies are available below for your reference.

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Documents in this collection

Acute Hospital Admissions and/or Inpatient Treatment Related to Non-Covered Services
Bariatric Surgery
Behavioral Health Care Authorization and Notification (PM)
Behavioral Health Services (Optum)
Cardiac Diagnostic Tests/Interventional Procedures (NIA)
Cervical Spine Surgeries (NIA)
Cholecystectomy Surgery
Diabetes Management Devices/CGMS
Durable Medical Equipment
Endoscopic Sinus Surgeries
Eye Procedures, Reconstructive
Gender Affirming Services(previously Transgender Health Services)
Gynecomastia Surgery
Hip Surgery (NIA)
Hip/Knee/Shoulder Surgeries (HKSS) Prior Authorization (PM)
Home Health Services
Home Infusion Therapy Services
Hysterectomy
Implantable Neurostimulators
Inpatient Rehabilitation / Long-Term Acute Care Hospital Services
Interventional Pain Management for Back Pain (NIA)
Knee Surgery (NIA)
Lumbar Spine Surgeries (NIA)
Medical Transportation
Molecular Diagnostic Management (AIM)
Molecular Diagnostic Testing Prior Authorization (PM)
Oncology and radiation oncology (OncoHealth/Oncology Analytics)
Outpatient Advanced Imaging Authorization (PM)
Outpatient Diagnostic Imaging (NIA)
Outpatient Physical and Occupational Therapy Services

Looking for Commercial Medical Necessity Guidelines?

Go to Commercial Medical Necessity Guidelines

Please note: This page includes medical necessity guidelines (both authorization and non-authorization) as well as some administrative authorization policies (which include a PM notation after the title); for questions, contact the Provider Service Center at 1-888-609-0692.

Questions about Medical Necessity Guidelines?

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