ModifiedMass General Brigham Health PlanPolicy 063

Medicare Advantage Administration Guidelines

Defines how Mass General Brigham Health Plan manages Medicare Advantage medical policies, the hierarchy of CMS guidance (NCDs/LCDs/LCAs), and when commercial or MassHealth policies are used; applies to plan members including OneCare and SCO.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedicare Advantage Administration Guidelines

Policy CodePolicy 063

Change TypeOff-cycle updates (Jan 2026) + prior annual additions

Effective Date

Next Review Date

Key ActionProviders must follow the Table 1 mapping and applicable CMS NCDs/LCDs or Mass General Brigham commercial policies when requesting medical necessity determinations; reference InterQual and Plan policies via the Provider Portal.

SourceLink

POLICY UPDATE CHANGES

Added policies to Table 1 including Fertility Services/Assisted Reproductive Services, Interventional Pain Management of the Spine, and DefenCath.

Removed retired policies including policy 04: Acute Inpatient, 76: Basivertebral Nerve Ablation, and 84: Epidural Steroid Injection.

Updated NCD/LCD information across many policies (e.g., Abecma, Acupuncture, Bariatric Surgery, Breast Surgeries, Carvykti, etc.).

Added multiple policies previously added in May 2025 (e.g., Vertebral Body Tethering, Elevidys, Vyjuvek, Omisirge, Casgevy, Amtagvi, Lyfgenia, Lenmeldy, Liposuction for Lipedema and Lymphedema, Epidural Steroid Injections, Breast Imaging, Medically Necessary Services, Tecelra, Aucatzyl).

CMS-guidedPrimary basis for Medicare Advantage determinations

InterQual®Utilized for medical necessity criteria

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Coverage Hierarchy and Applicability

General coverage hierarchy

Covered when the applicable authoritative guidance is met according to the following hierarchy

Hierarchy: 1) Follow applicable CMS National Coverage Determinations (NCDs) when present for the service; 2) If no NCD applies, follow Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) applicable to the member's Medicare Administrative Contractor jurisdiction; 3) When no CMS guidance (NCD/LCD/LCA) exists or CMS guidance is nonspecific, follow the Mass General Brigham Health Plan commercial medical policy; 4) For OneCare/SCO and other MassHealth situations, when CMS guidance is absent or insufficient, follow MassHealth criteria where specified before applying commercial policies.

Sources: chunks 3,5,6

Use of InterQual and Plan medical policies

When CMS guidance does not exist or is insufficient

InterQual or Plan Policy: Mass General Brigham Health Plan utilizes Change Healthcare InterQual® criteria for many services; when InterQual does not apply or is deemed insufficient, the Mass General Brigham Health Plan Medical Policy Committee develops and uses commercial medical policies to define medical necessity criteria.

Sources: chunks 3,16

Authority selection logic

For each listed service, the table indicates which policy or CMS determination to follow for Commercial (column 2), Medicare (column 1) and related mapping rules

Interpretation rule: If a CMS NCD/LCD/LCA is specific for the service, follow the CMS determination for Medicare Advantage members; if the CMS NCD/LCD is nonspecific or lacks sufficient specificity for consistent review, follow the Mass General Brigham Health Plan commercial medical policy for Medicare Advantage; when a member does not meet CMS criteria or no CMS criteria exist, follow MassHealth criteria where indicated (e.g., OneCare/SCO) before applying commercial policies.

Applies across table entries (see Table 1 mapping).

Coverage determination workflow

Plan coverage determination hierarchy

Hierarchy for Medicare Advantage medical necessity determinations: When CMS guidance (NCD/LCD/LCA or Medicare manuals) exists for a requested service, Mass General Brigham Health Plan uses that CMS guidance as the primary basis for medical necessity determinations for Medicare Advantage members.

Supported by references to use of NCDs/LCDs/LCAs as basis for determinations (chunk 40).

If no CMS guidance exists, the Plan uses Mass General Brigham Health Plan medical policies and InterQual criteria; for OneCare/SCO members, MassHealth criteria are used when specified.

Document states Plan uses InterQual and Plan medical policies when CMS guidance is absent and may use MassHealth criteria when specified (chunks 40,41).

When no available criteria from CMS/InterQual/Plan: If no medical necessity criteria are available from CMS, InterQual, or Plan medical policies, the request will be reviewed by a Medical Director who may solicit external specialist review.

Described in chunk 41.

No explicit global exclusions are stated in this excerpt. The policy does not provide a single list of universally excluded services; instead exclusions are handled within the Table 1 mappings and by reference to CMS guidance where applicable.

For certain payers (notably MassHealth and OneCare/SCO), some services may be designated as nonpayable. The table notes examples where MassHealth criteria apply or where there are no CMS criteria and instructs reviewers to follow MassHealth rules when indicated; specific rows in Table 1 identify services MassHealth ‘‘does not consider the service payable’’ (e.g., some genetic testing and other items called out in the table).

Services specifically listed in section 1862 of the Social Security Act (42 U.S.C. 1395y), which address statutory exclusions and Medicare as a secondary payer, are not covered by the Plan and will be denied per plan guidance.

When no CMS criteria (NCD/LCD) exist for a given service, the Plan may deem the service experimental/investigational if there is insufficient scientific evidence; in such cases Mass General Brigham commercial medical policy language governs coverage determinations. InterQual criteria are also used for services where applicable.

Reconstructive and cosmetic procedures are subject to CMS general exclusions and applicable LCDs. The policy references the Medicare Benefit Policy Manual Chapter 16 (General Exclusions from Coverage) and multiple LCDs relevant to plastic and reconstructive surgery; depending on whether CMS criteria are met, these services may be non‑covered.

Items removed from Table 1 (noted in the January 2026 off‑cycle update) are identified as retired and indicate noncoverage for Medicare Advantage members where applicable. The off‑cycle edits list policies that were removed (for example, Acute Inpatient, Basivertebral Nerve Ablation, and Epidural Steroid Injection), reflecting that specific policies in Table 1 are no longer active for Medicare Advantage when so indicated.

Referenced NCDs, LCDs and Code Lists

Referenced LCDs and NCDsmixed

L35022	LCD Identifier
L33796	LCD Identifier
L35001	LCD Identifier
L33822	LCD Identifier
L38664	LCD Identifier
L39611	LCD Identifier
L36029	LCD Identifier
L36668	LCD Identifier
L36707	LCD Identifier
L35724	LCD Identifier

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Referenced LCDs — subsetmixed

L39611	Urine Drug Testing
L36029	Urine Drug Testing
L36668	Urine Drug Testing
L36707	Urine Drug Testing
L35724	Urine Drug Testing
L34645	Urine Drug Testing

Referenced LCD — singlemixed

L33739

Speech Generating Devices (SGD)

Urine Drug Testing LCDsmixed

L39611	Urine Drug Testing
L36029	Urine Drug Testing
L36668	Urine Drug Testing
L36707	Urine Drug Testing
L35724	Urine Drug Testing
L34645	Urine Drug Testing

Speech Generating Devicesmixed

L33739

Speech Generating Devices (SGD) LCD

Transurethral Waterjet / Fluid Jet System LCDsmixed

38367	Fluid Jet System Treatment for LUTS/BPH
L38726	Transurethral Waterjet Ablation of the Prostate

Referenced LCDs — Interventional Pain and Spinemixed

L39015	Epidural Steroid Injections for Pain Management
L33906	Epidural Steroid Injections for Pain Management
L39240	Epidural Steroid Injections for Pain Management
L39242	Epidural Steroid Injections for Pain Management
L36920	Epidural Steroid Injections for Pain Management
L38994	Epidural Steroid Injections for Pain Management
L39054	Epidural Steroid Injections for Pain Management
L38773	Facet Joint Interventions for Pain Management
L33930	Facet Joint Interventions for Pain Management
L35936	Facet Joint Interventions for Pain Management

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What Providers Must Do

Prior Authorization

Prior Authorization Guidance (Table 1)

Follow the prior authorization guidance shown in Table 1 of the policy. Table 1 maps services to the applicable CMS guidance (NCDs, LCDs/LCAs, Medicare manuals) and to the Plan's commercial medical policies for Medicare Advantage members. Providers must use the Table 1 mapping to determine whether prior authorization is required for a requested service and which criteria to follow.

When Table 1 indicates a specific LCD/NCD/LCA applies, follow that CMS coverage determination for members in the applicable MAC jurisdiction.
When Table 1 indicates prior authorization is not required (for example, External Infusion Pumps per LCD L33794), no prior authorization is needed for Medicare Advantage members.
If Table 1 maps a service to the Mass General Brigham Health Plan commercial policy for Medicare Advantage members, follow that commercial policy for prior authorization and medical necessity requirements.

Denial Risk

LCD Adherence Required

Policy Purpose and Scope

This document explains how Mass General Brigham Health Plan applies Medicare (CMS) coverage guidance — including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) — as the primary basis for medical necessity determinations for Medicare Advantage members. When CMS guidance is absent or nonspecific, the Plan uses InterQual criteria, its own commercial medical policies, and where specified for OneCare/SCO members, MassHealth criteria. If no applicable criteria exist from CMS, InterQual, or Plan policies, a Medical Director review (with external specialist input as needed) will determine coverage.

Key Definitions

National Coverage Determination (NCD)

DefinitionDecisions by CMS defining the circumstances for Medicare coverage nationwide for a specific medical service, procedure, or device.

Role in plan determinationsWhen an applicable NCD exists, Mass General Brigham Health Plan follows the NCD for Medicare Advantage medical necessity determinations.

Fallback when absentIf there is no NCD for a service, Mass General Brigham Health Plan commercial medical policies are used for Medicare Advantage members.

Local Coverage Determination (LCD)

DefinitionA Local Coverage Determination (LCD) is a coverage decision published by a Medicare Administrative Contractor that applies based on the member's jurisdiction.

Requirement for determinationsMass General Brigham Health Plan is required to use the LCDs published by the member's Medicare Administrative Contractor jurisdiction when making coverage determinations.