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.
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).
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.