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Commercial Clinical/Authorization Policies

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Medical Drug Prior Authorization (CVS Health-Novologix)

Documents in this collection

Allergy Testing and Immunotherapy
Anterior Vertebral Body Tethering
Artificial Cervical Disc Replacement (NIA)
Bariatric Surgeries
Behavioral Health Care Prior Authorization & Notification (PM)
Behavioral Health Services (UBH)
Breast Surgeries
Bronchial Thermoplasty
Capsule Endoscopy
Cardiac Diagnostic Tests/InterventionalProcedures (NIA)
Cardiac Event Monitors
Cardiovascular Disease Risk Tests
Cervical Spine Surgeries (NIA)
Cholecystectomy
Cochlear Implants
Cosmetic and Reconstructive Eye Procedures
Cosmetic and Reconstructive Nasal Procedures
Cosmetic and Reconstructive Skin Procedures
COVID-19 Antibody Test
Covid-19 Monoclonal Antibody Therapy
Dental Benefit Clinical Review
Diabetes Management Devices
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)
Gynecomastia Surgery

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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 1-800-708-4414. 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 policies, please contact the Medical Management department at 617-509-8723.

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