Medical policies
Select a PDF or Word doc below to see medical necessity criteria for a specific treatment or service.
Medical policy listings
-
A - E
Abecma
Absorbent Products for Incontinence
Acupuncture
Acute Inpatient
Arthrodesis-for-Sacroiliac-Joint-Pain
Artificial Pancreas Device System
Assisted Reproductive Services/Infertility Services (Effective Date: January 1, 2023)
Autologous Chondrocyte Implantation in the Knee
Bariatric Surgery
Bone Growth Stimulator
Breast Surgeries
Breyanzi
Bronchial Thermoplasty
Carvytki
Chiropractic Services
Continuous Airway Devices (CareCentrix Guidelines)
Continuous Glucose Monitors (Effective March 1, 2023)
Corneal Collagen Cross-linking
Definition of Skilled Care
Dental Treatment Setting
Durable Medical Equipment (DME)
Early Intensive Behavioral Intervention
Enteral Nutrition Formulas and Supplements
Experimental and Investigational
Extended Care Facility
External-Counterpulsation -
F- M
Gender Affirming Procedures
Gender Affirming Procedures (Effective April 1, 2023)
Hearing Devices
HIV-Associated Lipodystrophy Syndrome
Home Health Care
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
Insulin Pumps
Intravenous Ketamine for Treatment-Resistant Depression
Kymriah
Lutathera (lutetium Lu 177 dotatate)
Luxturna
Medicare Advantage Administration Guidelines
Mobile Cardiac Outpatient Telemetry -
N - Z
Neuromodulation for Overactive Bladder and Fecal Incontinence (Effective March 1, 2023)
Non-Emergency Medically Necessary Transportation
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 (Effective March 1, 2023)
Prostatic Urethral Lift (Effective March 1, 2023)
Prostheses — Lower Limb
Prostheses — Upper Limb
Provenge
Pylarify and Gallium Ga-68 PSMA-11 Imaging for Patients with Prostate Cancer
Radiofrequency Ablation to Treat Uterine Fibroids (Effective March 1, 2023)
Reconstructive and Cosmetic Procedures
Sleep Studies (CareCentrix Guidelines)
Specialty Medication Administration — Site of Care
Speech Generating Devices
Tecartus
Therapeutic Lens
Tumor Treating Fields
UVB Home Phototherapy Units for Skin Disease
Vitamin D Screening and Testing in Adults
Yescarta
Zolgensma - English
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.