Medical policies

Below are links to the most up-to-date policies on treatment options for Fallon Health members. Each policy includes an overview, policy and criteria, an explanation of when services are covered, and any exclusions that apply.

All policies are downloadable PDFs, unless otherwise noted.

• Acute Inpatient Rehabilitation
• Allogeneic Stem Cell Transplantation
• Ambulatory Cardiac Monitoring (formerly known as Mobile Cardiac Telemetry)
• Anterior Segment Optical Coherence Tomography  
• Arthroscopy for Osteoarthritis of the Knee
• Artificial Disc Replacement, Cervical - retiring, effective December 1, 2023
• Artificial Disc Replacement, Lumbar - retiring, effective December 1, 2023
• Autologous Chondrocyte Implant 
• Autologous Stem Cell Transplantation
• Balloon Sinuplasty for Treatment of Chronic Sinusitis
• Bariatric Surgery
• Bone-Anchored Hearing Aids
• Bone Growth Stimulators
• Bronchial Thermoplasty
• CAR-T Cell Treatments
• Cochlear Implants
• Contact and Scleral Lens
• Continuous Interstitial Glucose Monitoring
• Cosmetic, Reconstructive, and Restorative Services
• Decompression, with or without Fusion - retiring, effective December 1, 2023
• Deep Brain Stimulation
• Durable Medical Equipment
• Enteral Nutrition, Low Protein Food Products and Special Medical Formulas
• Excimer Laser Skin Therapy
• Experimental and Investigational 
• Fecal Calprotectin Testing
• Fecal Microbiota Transplant
• Fusion - retiring, effective December 1, 2023
• Gender Affirmation Services
• Genetic Testing
• Hearing Aids for Plan Members 21 Years of Age or Younger
• High Frequency Chest Wall Oscillation Vest (The Vest)
• Hip Arthroscopy of Femoroacetabular Impingement 
• HIV-1 Co-receptor Tropism Assays
• Home Health Care Services
• Hyperbaric Oxygen Therapy
• Infertility Services
• Insulin Pumps
• Intensity Modulated Radiation Therapy (IMRT)
• Long-Term Acute Care (LTAC) 
• Effective December 1, 2023: Lower Limb Prostheses
• Lung Transplants
• Luxturna (voretigene neparvovec-rzyl)
• Medical Technology Assessment
• Neuropsychological Testing for Non-Behavioral Health Diagnoses
• Oral Appliances for Obstructive Sleep Apnea
• Orthognathic Surgery 
• Percutaneous Vertebroplasty and Kyphoplasty - retiring, effective December 1, 2023
• Posterior Tibial Nerve Stimulation
• Post-mastectomy Surgery and Services
• Prenatal Screening
• Effective December 1, 2023: Prostatic Urethral Lift
• Proton Beam Therapy
• Sacral Nerve Stimulation for Urinary Urge Incontinence
• Effective December 1, 2023: Sacroiliac Joint Fusion
• Scoliosis, Surgical Treatment - retiring, effective December 1, 2023
• Skilled Nursing Facility Level of Care
• Skin Substitutes
• Speech Generating Devices
• Speech Therapy
• Spinal Cord Stimulation
• Effective December 1, 2023: Spine Surgery
• Stereotactic Radiosurgery
• Stretch Devices for Joint Stiffness and Contractures
• Subcutaneous Implantable Defibrillators
• Surgery for Sleep Apnea (OSA) in Adults
• Transcutaneous Electric Nerve Stimulation (TENS) 
• Transplants, Solid Organ
• Transurethral Waterjet Ablation of Prostate
• Effective December 1, 2023: Trigger Point Injections
• Ultrasound-Guided Transcervical Radiofrequency Ablation of Uterine Fibroids
• Urine Drug Screening
• Vagus Nerve Stimulation
• Varicose Veins of the Lower Extremities 
• Ventricular Assist Devices
• Wireless Capsule Endoscopy
• Zolgensma (onasemnogene abeparvovec-xioi)

InterQual® criteria is available through the Utilization Management Department upon request.