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
Absorbent Products for Incontinence (Effective Jan 1, 2026)
Acupuncture
Acupuncture (Effective Jan 1, 2026)
Administratively Necessary Days
Administratively Necessary Days (Effective Jan 1, 2026)
Adstiladrin
Adstiladrin (Effective Jan 1, 2026)
Amtagvi
Assisted Reproductive Services/Fertility Services (see Fertility Services/Assisted Reproductive Services)
Assisted Reproductive Services/Infertility Services (see Infertility Services/Assisted Reproductive Services)
Aucatzyl
Autologous Chondrocyte Implantation in the Knee
Autologous Chondrocyte Implantation in the Knee (Effective Jan 1, 2026)
Balloon Dilation of the Eustachian Tube
Balloon Dilation of the Eustachian Tube (Effective Jan 1, 2026)
Bariatric Surgery
Bariatric Surgery (Effective Jan 1, 2026)
Bone Growth Stimulator
Bone Growth Stimulators (Effective Jan 1, 2026)
Breast Imaging
Breast Imaging (Effective Jan 1, 2026)
Breast Surgeries
Breast Surgeries (Effective Jan 1, 2026)
Breyanzi
Carvytki
Casgevy
Chiropractic Services
Chiropractic Services (Effective Jan 1, 2026)
Continuous Glucose Monitors
Continuous Glucose Monitors (Effective Jan 1, 2026)
Corneal Collagen Cross-linking
Corneal Collagen Cross-Linking (Effective Jan 1, 2026)
DefenCath
Definition of Skilled Care
Definition of Skilled Care (Effective Jan 1, 2026)
Dental Treatment Setting
Dental Treatment Setting (Effective Jan 1, 2026)
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) (Effective Jan 1, 2026)
Early Intensive Behavioral Intervention
Early Intensive Behavioral Intervention (Effective Jan 1, 2026)
Elevidys
Enteral Nutrition Formulas and Supplements
Enteral Nutrition Formulas and Supplements (Effective Jan 1, 2026)
Experimental and Investigational
Experimental and Investigational (Effective Jan 1, 2026)
Extended Care Facility
Extended Care Facility (Effective Jan 1, 2026)
Fertility Services/Assisted Reproductive Services
Fertility Services/Assisted Reproductive Services (Effective Jan 1, 2026)
Gender Affirming Procedures
Gender Affirming Procedures (Effective Jan 1, 2026)
Hearing Devices
Hearing Devices (Effective Jan 1, 2026)
Hemgenix
HIV-Associated Lipodystrophy Syndrome
HIV-Associated Lipodystrophy Syndrome (Effective Jan 1, 2026)
Home Health Care
Home Health Care (Effective Jan 1, 2026)
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (Effective Jan 1, 2026)
IB-Stim
IB-Stim (Effective Jan 1, 2026)
Infertility Services/Assisted Reproductive Services
Infertility Services/Assisted Reproductive Services (Effective Jan 1, 2026)
Insulin Pumps
Insulin Pumps (Effective Jan 1, 2026)
Interventional Pain Management of the Spine
Interventional Pain Management of the Spine (Effective Jan 1, 2026)
Intravenous Ketamine for Treatment-Resistant Depression
Kymriah
Lenmeldy
Liposuction for the Treatment of Lipedema and Lymphedema
Liposuction for the Treatment of Lipedema and Lymphedema (Effective Jan 1, 2026)
Lutathera (lutetium Lu 177 dotatate)
Lutathera (Effective Jan 1, 2026)
Luxturna
Lyfgenia
Medically Necessary Services
Medically Necessary Services (Effective Jan 1, 2026)
Medicare Advantage Administration Guidelines
Medicare Advantage Administration Guidelines (Effective Jan 1, 2026)
Magnetic Resonance-Guided Focused Ultrasound
Magnetic Resonance-Guided Focused Ultrasound (Effective Jan 1, 2026)
Neuromodulation for Overactive Bladder and Fecal Incontinence
Neuromodulation for Overactive Bladder and Fecal Incontinence (Effective Jan 1, 2026)
Non-Emergency Medically Necessary Transportation
Non-Emergency Medically Necessary Transportation (Effective Jan 1, 2026)
Omisirge
Omisirge (Effective Jan 1, 2026)
Oral and Maxillofacial Surgery and Procedures
Oral and Maxillofacial Surgery and Procedures (Effective Jan 1, 2026)
Out of Network Providers
Out of Network Providers (Effective Jan 1, 2026)
Outpatient Chest Physical Therapy
Outpatient Chest Physical Therapy (Effective Jan 1, 2026)
Outpatient Drug Screening and Testing
Outpatient Drug Screening and Testing (Effective Jan 1, 2026)
Phototherapeutic Keratectomy
Phototherapeutic Keratectomy (Effective Jan 1, 2026)
Phototherapy & Photo Chemotherapy for Dermatologic Conditions
Phototherapy & Photochemotherapy for Dermatologic Conditions (Effective Jan 1, 2026)
Pluvicto
Pluvicto (Effective Jan 1, 2026)
Preimplantation Genetic Testing
Preimplantation Genetic Testing (Effective Jan 1, 2026)
Prostate-Specific Membrane Antigen Imaging for Patients with Prostate Cancer
Prostate-Specific Membrane Antigen Imaging for Patients with Prostate Cancer (Effective Jan 1, 2026)
Prostatic Urethral Lift
Prostatic Urethral Lift (Effective Jan 1, 2026)
Prostheses — Lower Limb
Prostheses - Lower Limb (Effective Jan 1, 2026)
Prostheses — Upper Limb
Prostheses - Upper Limb (Effective Jan 1, 2026)
Provenge
Provenge (Effective Jan 1, 2026)
Radiofrequency Ablation to Treat Uterine Fibroids
Radiofrequency Ablation to Treat Uterine Fibroids (Effective Jan 1, 2026)
Reconstructive and Cosmetic Procedures
Reconstructive and Cosmetic Procedures (Effective Jan 1, 2026)
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 Jan 1, 2026)
Tecartus
Tecelra
Therapeutic Lens
Therapeutic Lens (Effective Jan 1, 2026)
Transurethral Waterjet Ablation of the Prostate
Transurethral Waterjet Ablation of the Prostate (Effective Jan 1, 2026)
UVB Home Phototherapy Units for Skin Disease
UVB Home Phototherapy Units for Skin Disease (Effective Jan 1, 2026)
Vertebral Body Tethering
Vertebral Body Tethering (Effective Jan 1, 2026)
Vitamin D Screening and Testing in Adults
Vitamin D Screening and Testing in Adults (Effective Jan 1, 2026)
Vyjuvek
Yescarta
Zolgensma
Zolgensma (Effective Dec 1, 2025)
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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Mass General Brigham Health Plan includes Mass General Brigham Health Plan, Inc.
and Mass General Brigham Health Insurance Company