Fallon_community_health_plan_inc Coverage Criteria
- Fallon_community_health_plan_inc prior authorization
- Fallon_community_health_plan_inc timely filing
- All Fallon_community_health_plan_inc policy updates
Latest Fallon_community_health_plan_inc coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Fecal microbiota transplantation for recurrent Clostridioides difficile infectionThis policy governs medical necessity and prior authorization requirements for fecal microbiota-based therapies (including conventional FMT and FDA-approved products Rebyota and VOWST) to prevent recurrent C. difficile infection for Fallon Health members and selected Fallon products.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Treatment of Sleep Disordered Breathing in Adults and ChildrenClinical guideline for coverage and medical necessity criteria for positive airway pressure (PAP) therapies (CPAP, APAP, bi-level, ASV) for adults and children with sleep-disordered breathing; intended for Fallon Community Health Plan providers and claim reviewers.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Radiofrequency Ablation of Uterine Fibroids Clinical Coverage CriteriaClinical coverage criteria for laparoscopic and transcervical radiofrequency ablation of symptomatic uterine fibroids for Fallon Community Health Plan products, with specific MassHealth coverage provisions.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Skilled Nursing Facility (SNF) level of careDefines Fallon Health clinical coverage criteria for SNF level of care, who requires prior authorization, and when admission and continued stay in a SNF are covered for Fallon products and members.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Community-Based LTSS Services Clinical Coverage CriteriaDefines Fallon Community Health Plan's clinical coverage criteria, prior authorization requirements, provider qualifications, service limits, and documentation standards for a range of community-based long-term services and supports (LTSS) for NaviCare HMO SNP members.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Day Habilitation (DH) — Coverage Criteria and Prior AuthorizationDefines Fallon Health coverage, prior authorization, clinical criteria, documentation, coding, exclusions, and limitations for community-based Day Habilitation services for members with intellectual or developmental disabilities.All fallon_community_health_plan_inc updates
- Coverage CriteriaEff. 2025-11-25Surgery for Obstructive Sleep Apnea — Clinical Coverage CriteriaClinical coverage criteria governing prior authorization and medical necessity determinations for surgical treatments of obstructive sleep apnea for Fallon Health plan members, including Medicare Advantage and Community Care products; includes references to InterQual criteria and exclusions.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Hypoglossal Nerve Stimulation Clinical Coverage CriteriaDefines Fallon Health prior-authorization and medical necessity criteria for hypoglossal nerve stimulation (HNS) implants and related procedures for Fallon Health plan members, including product- and population-specific variations and exclusions.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-01Orthognathic Surgery Clinical Coverage CriteriaClinical coverage criteria for orthognathic surgery (surgical correction of mandibular and/or maxillary skeletal abnormalities) including applicability to Fallon Health products and Medicare/Community Care variations; affects providers seeking prior authorization for members.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Anterior Segment Optical Coherence Tomography Clinical Coverage CriteriaDefines Fallon Community Health Plan's coverage stance and medical necessity criteria for anterior segment OCT imaging of the eye for Fallon Health products and MassHealth ACO/Community Care members.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Durable Medical Equipment Clinical Coverage CriteriaDefines Fallon Community Health Plan's medical necessity, prior authorization, rental/purchase, and exclusion rules for durable medical equipment for plan members, and describes hierarchy of guidance applied by product (Medicare, MassHealth, Dual, Community Care, PACE).All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Home Health Services Clinical Coverage CriteriaDefines medical necessity, authorization, and documentation requirements for home health services provided to Fallon Health members and describes program variations for Medicare Advantage, MassHealth, NaviCare, and PACE. Affects providers requesting prior authorization for home health services.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-05-01Lung Transplantation — Clinical Coverage CriteriaClinical coverage criteria for single or bilateral lung transplantation (including pediatric considerations, lobar and re-transplantation) applicable to Fallon Health products; governs prior authorization and medical necessity determinations for covered members.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-04-01Kymriah (tisagenlecleucel) clinical coverage criteriaDefines Fallon Community Health Plan's medical necessity, prior authorization, and coverage criteria for Kymriah (tisagenlecleucel) for applicable Fallon products and describes clinical context and exclusions for pediatric and adult hematologic indications.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-04-01Luxturna (voretigene neparvovec-rzyl) Clinical Coverage CriteriaClinical coverage criteria and prior authorization requirements for Luxturna for Fallon Community Health Plan members, including product description, medical necessity criteria, coding, and payer-specific variations (Medicare, MassHealth). Applies to Fallon Health products listed in the policy.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-04-01Zolgensma (onasemnogene abeparvovec-xioi) Clinical Coverage CriteriaClinical coverage criteria and prior authorization requirements for single-dose intravenous Zolgensma for pediatric patients under 2 years with SMA, applicable to Fallon Health products including Fallon Medicare Plus, NaviCare, and Community Care.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-03-01Transplants, Solid Organ Clinical Coverage CriteriaDefines Fallon Community Health Plan's coverage policy, prior authorization requirements, and clinical criteria for solid organ transplants (liver, kidney, pancreas, intestine, heart, heart‑lung and related combinations) for applicable Fallon products; affects providers requesting transplant authorization and transplant centers.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-01Capsule endoscopy (esophagus, small bowel, colon) — Coverage and prior authorizationDefines Fallon Health coverage, prior authorization, and medical necessity criteria for capsule endoscopy of the esophagus (CPT 91111), small bowel/esophagus through ileum (CPT 91110), and colon (CPT 91113) for specified Fallon products.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-11-21Prenatal Screening Clinical Coverage CriteriaClinical coverage criteria for prenatal aneuploidy screening (including cell-free DNA/NIPS), various serum/ultrasound screening options, and carrier genetic testing for Fallon Community Health Plan members; describes what is covered, exclusions, and payer-specific variations.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-01Cochlear Implants Clinical Coverage CriteriaDefines Fallon Health coverage, prior authorization, and medical necessity determination processes for cochlear implantation and related components across Fallon products; applies to clinicians requesting services for Fallon members.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-01Peripheral nerve blocks (peripheral nerve/ganglion injections) - Coverage and clinical criteriaCoverage and clinical criteria for diagnostic and therapeutic peripheral nerve blocks for Fallon Health products, describing when blocks are medically reasonable and necessary, limitations, exclusions, and variations for Medicare and MassHealth.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-01Posterior Tibial Nerve Stimulation Clinical Coverage CriteriaThis policy defines medical necessity criteria, exclusions, and coding guidance for posterior tibial nerve stimulation (PTNS) to treat symptomatic non-neurogenic overactive bladder (OAB) for Fallon Health products; it affects specialists (typically urologists or urogynecologists) and providers delivering PTNS and related services.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-01Proton Beam Therapy (PBT) Clinical Coverage CriteriaClinical coverage criteria and prior authorization requirements for proton beam therapy applied to Fallon Health products, including Medicare Advantage, MassHealth, NaviCare, PACE, and Community Care members.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-01Vagus Nerve Stimulation (implantable and noninvasive) Coverage CriteriaDefines Fallon Health coverage, prior authorization, and medical necessity criteria for implantable vagus nerve stimulation (VNS) and addresses noninvasive/transcutaneous VNS; applies to Fallon Community products listed and notes Medicare/MassHealth variations.All fallon_community_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-01Deep Brain Stimulation (DBS) Clinical Coverage CriteriaClinical coverage criteria for deep brain stimulation (DBS) including indications, limitations, device approvals, required provider/facility capabilities, and pediatric considerations; applies to specified Fallon Health product lines and MassHealth/Community Care members. Prior authorization is required.All fallon_community_health_plan_inc updates
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Tool Description
Search Fallon_community_health_plan_inc coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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