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Commercial Medical Necessity Guidelines

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Medical Benefit Drugs: Medical Necessity Guidelines

Documents in this collection

Allergy Testing and Immunotherapy
Anterior Vertebral Body Tethering
Artificial Cervical Disc Replacement (NIA)
Assisted Reproductive Technology Services – Massachusetts Products
Assisted Reproductive Technology Services – New Hampshire Products
Bariatric Surgeries
Behavioral Health Care Prior Authorization & Notification (PM)
Behavioral Health Services (UBH)
Blepharoplasty, Upper/Lower Eyelid and Brow and/or Eyelid Ptosis Repair(Formerly Cosmetic and Reconstructive Eye Procedures)
Breast Pumps
Bronchial Thermoplasty
Cardiac Diagnostic Tests/InterventionalProcedures (NIA)
Cardiac Event Monitors
Cardiovascular Disease Risk Tests
Cervical Spine Surgeries (NIA)
Cholecystectomy
Clinical Trials: Routine Costs Medical Policy
Cochlear Implants
Comprehensive Genomic Profiling with FoundationOne CDx or FoundationOne Liquid CDx to Guide Cancer Treatment in Patients with Advanced Cancer
Continuous Glucose Monitoring and Diabetes Management Devices
COVID-19 Antibody Test
Covid-19 Monoclonal Antibody Therapy
Dental Benefit Clinical Review
Drug Dosage and Frequency
Durable Medical Equipment Prior Authorization (PM)
Endoscopic Sinus Surgeries
Esophagogastroduodenoscopy (EGD)
Fecal Microbial Transplant (FMT) For Clostridium Difficile Infection
Formulas and Enteral Nutrition
Gender Affirming Services(formerly Transgender Health Services)

Looking for Medicare Medical Necessity Guidelines?

Go to Medicare 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). See below for more information on medical necessity guidelines; for questions, contact the Provider Service Center at 1-800-708-4414. In addition to these policies, please refer to the Referral, Notification, and Authorization section of the commercial Provider Manual for our notification and referral policies.

About Our Medical Criteria

Harvard Pilgrim uses written criteria based on sound clinical evidence to evaluate the medical appropriateness of health care services. These criteria are objective and based on current clinical and medical evidence and applied with consideration of individual needs and characteristics (e.g., age, comorbidities, prior treatment and complications) and the availability of services within the local delivery system. For a hard copy of these guidelines, please contact the Medical Management department at 617-509-8723.

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Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Together, we're delivering ever-better health care experiences to everyone in our diverse communities.

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