Medical policies
Select a PDF or Word doc below to see medical necessity criteria for a specific treatment or service.
Medical policy listings
Abecma
Absorbent Products for Incontinence
Acupuncture
Administratively Necessary Days
Adstiladrin
Amtagvi
Aucatzyl
Autologous Chondrocyte Implantation in the Knee
Balloon Dilation of the Eustachian Tube
Bariatric Surgery
Bone Growth Stimulator
Breast Imaging
Breast Surgeries
Breyanzi
Carvytki
Casgevy
Chiropractic Services
Continuous Glucose Monitors
Corneal Collagen Cross-linking
DefenCath
Definition of Skilled Care
Dental Treatment Setting
Durable Medical Equipment (DME)
Early Intensive Behavioral Intervention
Elevidys
Enteral Nutrition Formulas and Supplements
Experimental and Investigational
Extended Care Facility
Fertility Services/Assisted Reproductive Services
Gender Affirming Procedures
Hearing Devices
Hemgenix
HIV-Associated Lipodystrophy Syndrome
Home Health Care
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
IB-Stim
Infertility Services/Assisted Reproductive Services
Infertility Services/Assisted Reproductive Services (Effective 9/1/2025)
Insulin Pumps
Interventional Pain Management of the Spine
Intravenous Ketamine for Treatment-Resistant Depression
Kymriah
Lenmeldy
Liposuction for the Treatment of Lipedema and Lymphedema
Lutathera (lutetium Lu 177 dotatate)
Luxturna
Lyfgenia
Medically Necessary Services
Medicare Advantage Administration Guidelines
Neuromodulation for Overactive Bladder and Fecal Incontinence
Non-Emergency Medically Necessary Transportation
Omisirge
Oral and Maxillofacial Surgery and Procedures
Out of Network Providers
Outpatient Chest Physical Therapy
Outpatient Drug Screening and Testing
Phototherapeutic Keratectomy
Phototherapy & Photo Chemotherapy for Dermatologic Conditions
Pluvicto
Preimplantation Genetic Testing
Prostate-Specific Membrane Antigen Imaging for Patients with Prostate Cancer
Prostatic Urethral Lift
Prostheses — Lower Limb
Prostheses — Upper Limb
Provenge
Radiofrequency Ablation to Treat Uterine Fibroids
Reconstructive and Cosmetic Procedures
Roctavian
Skysona
Sleep Studies (Diagnosis of Sleep Disordered Breathing- CareCentrix Guidelines)
Sleep Studies (Treatment of Sleep Disordered Breathing-Centrix Guidelines)
Specialty Medication Administration - Site of Care
Speech Generating Devices
Speech Generating Devices (Effective 9/1/2025)
Tecartus
Tecelra
Therapeutic Lens
Transurethral Waterjet Ablation of Prostate
UVB Home Phototherapy Units for Skin Disease
Vertebral Body Tethering
Vitamin D Screening and Testing in Adults
Vyjuvek
Yescarta
Zolgensma
Zynteglo
Clinical criteria do not certify coverage availability.
Please refer to the current Mass General Brigham Health Plan provider manual for a definition of “medical necessity.” Criteria may be amended or rescinded at any time by Mass General Brigham Health Plan and Mass General Brigham Health Plan shall have the exclusive right to interpret and enforce its terms.
Confirming coverage is easy
To verify services under a specific plan or to ask about guidelines not listed here, simply contact Provider Services at 800-462-5449.
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and Mass General Brigham Health Insurance Company