CurrentMass General Brigham Health PlanPolicy 063

Medicare Advantage Administration Guidelines

Describes how Mass General Brigham Health Plan applies CMS guidance (NCDs, LCDs, LCAs, Medicare manuals) and InterQual/commercial medical policies to determine medical necessity and coverage for Medicare Advantage members; includes a Table 1 mapping plan medical policies to applicable NCDs/LCDs and notes annual/off-cycle updates to that table.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedicare Advantage Administration Guidelines

Policy CodePolicy 063

Change TypeAnnual update + off‑cycle additions/removals

Effective DateJan 1, 2025

Next Review Date

Key ActionFor Medicare Advantage members, document and apply applicable CMS NCDs/LCDs/LCAs and Medicare manual criteria when determining medical necessity.

SourceLink

POLICY UPDATE CHANGES

Annual 2025 update: edits to Table 1 including renumbering Zynteglo and updates to NCD/LCD information for multiple policies and additions/removals to Table 1.

January 2024 annual update: administrative changes to coverage guidelines and Medical Policy Committee language; intent unchanged.

Off-cycle updates in 2023 and 2024 adding specific therapies (e.g., Roctavian, Adstiladrin, Hemgenix) to Table 1.

Removed retired policies from Table 1 (e.g., Arthrodesis of Sacroiliac Joint Pain, Artificial Pancreas Device System, Mobile Cardiac Outpatient Telemetry, Bronchial Thermoplasty, Tumor Treating Fields).

~088Table 1 entries referenced

2025-01Most recent annual update

multipleCMS guidance sources cited

Policy summary and scope

This administrative guideline defines the hierarchy used to determine coverage for Medicare Advantage members: CMS NCDs, LCDs, LCAs and Medicare manuals take precedence; when CMS guidance is not available, the Plan follows Mass General Brigham Health Plan commercial medical policies and Change Healthcare InterQual criteria. Table 1 maps many plan medical policies to applicable CMS guidance and is maintained with periodic updates.

Effective/Last review date: 2025-01-01 (Annual 2025 update).

Key facts

policy_number063

subjectMedicare Advantage Administration Guidelines

statusCURRENT

effective date2025-01-01

last_review2025-01-01

next_review

scope_summaryApplies CMS NCDs/LCDs/LCAs and Medicare manuals first for Medicare Advantage members; when absent or insufficient, uses Mass General Brigham commercial medical policies and Change Healthcare InterQual criteria; includes Table 1 mapping policies to CMS guidance and records periodic updates.

Coverage determination hierarchy and exclusions

General Coverage Determination Hierarchy

Mass General Brigham Health Plan follows CMS guidance where available; otherwise commercial policy or InterQual is used; medical director review if no criteria exist.

National Coverage Determination (NCD) governs: When a CMS National Coverage Determination (NCD) exists for a service, the NCD governs coverage for Medicare Advantage members.
Local Coverage Determination (LCD)/Local Coverage Article (LCA) governs: When a Local Coverage Determination (LCD) or Local Coverage Article (LCA) exists from the appropriate MAC jurisdiction, the LCD/LCA governs coverage for members in that jurisdiction.
Commercial medical policy fallback: When no CMS guidance (NCD/LCD/LCA) exists for the requested service, Mass General Brigham Health Plan commercial medical policies are used to determine medical necessity.

Table 1 mapping rules and examples

Table 1 Mapping Rules

Table 1 maps many plan medical policies to applicable CMS NCDs/LCDs/LCAs; where an NCD/LCD 'lacks sufficient specificity' the commercial policy is followed. Examples include:

Examples from Table 1

Abecma / CAR T: Abecma = NCD: Chimeric Antigen Receptor (CAR) T-cell Therapy (110.24) lacks sufficient specificity; follow Mass General Brigham commercial policy.
Acupuncture NCD: Acupuncture = NCD: Acupuncture for Chronic Lower Back Pain (30.3.3).
Bariatric Surgery NCD: Bariatric Surgery = NCD: Bariatric Surgery for the Treatment of Morbid Obesity (100.1).

Referenced CMS NCDs / LCDs and examples

Referenced LCD/NCD identifiers and examples cited in documentmixed

110.24	NCD: Chimeric Antigen Receptor (CAR) T-cell Therapy
30.3.3	NCD: Acupuncture for Chronic Lower Back Pain
100.1	NCD: Bariatric Surgery for Treatment of Morbid Obesity
L33796	LCD: Osteogenesis Stimulators
L33822	LCD: Glucose Monitors
L38664	LCD: Implantable Continuous Glucose Monitors (I-CGM) (example)
L38387	LCD: Hypoglossal Nerve Stimulation for OSA
L33794	LCD: External Infusion Pumps
50.3	NCD: Cochlear Implantation
L33739	LCD: Speech Generating Devices

1–10 of 16

1/2

Examples of NCD/LCD identifiers cited in the guideline include NCDs such as 110.24 (CAR T-cell Therapy), 30.3.3 (Acupuncture for Chronic Lower Back Pain), and 100.1 (Bariatric Surgery), and LCDs such as L33796 (Osteogenesis Stimulators) and L33822 (Glucose Monitors); Table 1 contains many additional mappings. When an LCD/LCA applies, readers should use the Medicare Administrative Contractor (MAC) jurisdiction LCD/LCA corresponding to the member's residence unless CMS specifies otherwise.

What clinicians and billing staff must do

Documentation Required

Use CMS guidance first

For Medicare Advantage members, document and apply applicable CMS NCDs/LCDs/LCAs and Medicare manual criteria when determining medical necessity.

Documentation Required

Use commercial policy when CMS guidance absent or insufficient

When CMS guidance does not exist or an NCD/LCD "lacks sufficient specificity", use Mass General Brigham Health Plan commercial medical policy or InterQual criteria and document rationale.

Key definitions

Definitions

NCDNational Coverage Determination created by CMS defining coverage nationwide for specific services, procedures, or devices.

LCDLocal Coverage Determination issued by a Medicare Administrative Contractor (MAC) for its jurisdiction to guide coverage of services.

InterQualChange Healthcare InterQual criteria used by the Plan for medical necessity determinations where applicable.

Document revisions and change log

2025-01 (Annual 2025 update)revisedLatest

Annual 2025 update: edits to Table 1 including renumbering Zynteglo; updated NCD/LCD information for multiple policies (Abecma, Acute Inpatient, Bariatric Surgery, Breast Surgeries, Breyanzi, Continuous Glucose Monitors, Home Health Care, Kymriah, Luxturna, Neuromodulation, Outpatient Drug Screening, Tecartus, Therapeutic Lens, Vitamin D screening, Yescarta, Carvykti, Skysona, Transurethral Waterjet Ablation, Vertebral Body Tethering); added multiple entries (Elevidys, Vyjuvek, Casgevy, Omisirge, Basivertebral Nerve Ablation, Amtagvi, Lyfgenia, Lenmeldy, Epidural Steroid Injections, Liposuction for Lipedema and Lymphedema, Breast Imaging, Medically Necessary Services, Tecelra, Aucatzyl); marked Absorbent Products for Incontinence as not covered for Medicare Advantage members.

January 2024 (Annual 2024 update)revised

January 2024 annual update: administrative changes to coverage guidelines and Medical Policy Committee language; high-tech radiology section removed and references updated; intent unchanged.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedicare Advantage Administration Guidelines

Policy CodePolicy 063

Change TypeAnnual update + off‑cycle additions/removals

Effective DateJan 1, 2025

Next Review Date

Key ActionFor Medicare Advantage members, document and apply applicable CMS NCDs/LCDs/LCAs and Medicare manual criteria when determining medical necessity.

SourceLink

On This Page

InterQual criteria use: Mass General Brigham Health Plan uses Change Healthcare InterQual criteria (including InterQual Medicare DME criteria) as applicable for medical necessity determinations.

Medical director review fallback: If no criteria are available from CMS, InterQual, or Mass General Brigham Health Plan policies, a medical director will review the request and may consult external specialists.

(metadata): Document basis: apply CMS guidance first, then plan commercial policies or InterQual; medical director review when none exist.

Exclusions

Plan follows statutory exclusions and Medicare rules.

Medicare statutory exclusions: Services listed in section 1862 of the Social Security Act (42 U.S.C. 1395y) are not covered by the plan (Medicare statutory exclusions).

Bone Growth Stimulators / Breast Surgeries: Bone Growth Stimulators = LCD: Osteogenesis Stimulators (L33796) and related plastic surgery LCDs; follow commercial policy for breast reconstruction and gender-affirming procedures as indicated.

Continuous Glucose Monitors (CGMs): Continuous Glucose Monitors = LCD: Glucose Monitors (L33822) and related LCDs/LCAs; prior authorization is not required as noted in Table 1.

Durable Medical Equipment (DME): Durable Medical Equipment = NCD: Durable Medical Equipment Reference List (280.1) and relevant LCDs; use InterQual DME criteria where indicated.

Hypoglossal Nerve Stimulation = LCD: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38387).

Insulin Pumps = LCD: External Infusion Pumps (L33794); prior authorization is not required as noted in Table 1.

Cochlear Implant NCD: Cochlear Implant = NCD: Cochlear Implantation (50.3).

Speech Generating Devices (SGD): Speech Generating Devices = LCD: Speech Generating Devices (L33739).

Sacral Nerve Stimulation = NCD: Sacral Nerve Stimulation for Urinary Incontinence (230.18) and related LCDs for posterior tibial nerve stimulation.

Outpatient Drug Testing: Outpatient Drug Screening and Testing = follow Mass General Brigham commercial policy; referenced urine drug testing LCDs (e.g., L36037) are listed in Table 1.

Specialty / high-tech therapies: Many specialty/high-tech therapies (e.g., CAR T-cell products, gene therapies, novel drugs/devices) are listed in Table 1 with either NCD/LCD mapping or instruction to follow Mass General Brigham commercial policy.

Table 1 in the guideline lists many specific plan medical policies mapped to NCDs, LCDs, and LCAs; some CMS guidance may "lack sufficient specificity," in which case the Table instructs to follow the Mass General Brigham Health Plan commercial policy. Table 1 also notes certain prior authorization exceptions (for example, Continuous Glucose Monitors and Insulin Pumps are indicated as prior authorization is not required).

Prior Authorization

Medical director review when no criteria exist

If no CMS, InterQual, or Mass General Brigham policy criteria exist for a requested service, submit for medical director review; the medical director may consult external specialists.

Billing Rule

Follow LCD jurisdiction

Apply the LCD/LCA corresponding to the Medicare Administrative Contractor (MAC) jurisdiction of the member's residency unless CMS specifies otherwise; ensure claims/billing align with that LCD.

Documentation Required

Follow InterQual where indicated

Use Change Healthcare InterQual criteria where the Plan identifies InterQual applicability (e.g., DME, Home Health, level of care determinations) and retain supporting documentation.

December 2023 (Off-cycle update)added

Off-cycle updates: December 2023 — Roctavian added to Table 1.

September 2023 (Off-cycle update)added

Off-cycle updates: September 2023 — Adstiladrin added to Table 1.

August 2023 (Off-cycle update)added

Off-cycle updates: August 2023 — Transurethral Waterjet Ablation of the Prostate and Hemgenix added to Table 1.

2025-01 (Annual 2025 update)removed

Removed retired policies from Table 1 during the 2025 update: Arthrodesis of Sacroiliac Joint Pain; Artificial Pancreas Device System; Mobile Cardiac Outpatient Telemetry; Bronchial Thermoplasty; Tumor Treating Fields.

Recent changes include the Annual 2025 edits to Table 1 (renumbering Zynteglo; updates and additions such as Elevidys, Vyjuvek, Casgevy, Omisirge, Basivertebral Nerve Ablation; and removal of retired policies), multiple off-cycle additions in 2023–2024 (e.g., Roctavian, Adstiladrin, Hemgenix), removal of retired policies, and administrative housekeeping such as the removal of the high-tech radiology section.