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
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
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 -
F- M
Gender Affirming Procedures
Hearing Devices
Hemgenix
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
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
Prostatic Urethral Lift
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
Reconstructive and Cosmetic Procedures
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
Tecartus
Therapeutic Lens
Transurethral Waterjet Ablation of Prostate (Effective Date: July 1, 2023)
Tumor Treating Fields
UVB Home Phototherapy Units for Skin Disease
Vertebral Body Tethering
Vitamin D Screening and Testing in Adults
Yescarta
Zolgensma
Zynteglo - 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.