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Medicare Advantage Clinical/Auth. Policies

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 clinical/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
Antiemetics: Aloxi, Anzemet and Emend
Bariatric Surgery
Behavioral Health Care Authorization and Notification (PM)
Behavioral Health Services (Optum)
Cardiac Diagnostic Tests/Interventional Procedures (NIA)
Cervical Spine Surgeries (NIA)
Chest Wall Deformities Reconstructive and Restorative Procedures
Cholecystectomy Surgery
Diabetes Management Devices/CGMS
Durable Medical Equipment
Endoscopic Sinus Surgeries
Entyvio (Vedolizumab)
Eye Reconstructive and Restorative Procedures
Eylea (aflibercept)
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)
Intravenous Immune Globulin (IVIG)
Knee Surgery (NIA)
Kymriah (tisagenlecleucel)
Lucentis (ranibizumab)
Lumbar Spine Surgeries (NIA)
Medical Transportation

Looking for Commercial Policies?

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

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