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
• Anterior Segment Optical Coherence Tomography  
• Arthroscopy for Osteoarthritis of the Knee
• Autologous Chondrocyte Implantation 
• Autologous Stem Cell Transplantation
• Balloon Sinus Ostial Dilation
• Bariatric Surgery
• Bone-Anchored Hearing Aids 
• Bone Growth Stimulators
• Bronchial Thermoplasty
• Capsule Endoscopy
• Cochlear Implants
• Corneal and Scleral Contact Lenses 
• Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Systems
• Cosmetic, Reconstructive, and Restorative Services
• Deep Brain Stimulation
• Durable Medical Equipment
• Current policy
• Revised policy, effective July 1, 2025
• Enteral Nutrition, Low Protein Food Products and Special Medical Formulas
• Excimer Laser Skin Therapy
• Fecal Calprotectin Testing
• Fecal Microbiota Transplant
• Gender Affirmation Services
• Genetic Testing
• Hearing Aids for Community Care Plan Members 21 Years of Age or Younger
• High Frequency Chest Wall Oscillation Vest (The Vest)
• Hip Arthroscopy of Femoroacetabular Impingement 
• Home Health Care Services
• Current policy
• Revised policy, effective July 1, 2025
• Hospital Beds with Added Safety Enclosure
• Hyperbaric Oxygen Therapy
• Hypoglossal Nerve Stimulation
• Implantable Cardioverter Defibrillators
• Infertility Services
• Intensity Modulated Radiation Therapy (IMRT)
• Kymriah (tisagenlecleucel)
• Long-Term Acute Care (LTAC) 
• 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 
• Peripheral Nerve Blocks
• Posterior Tibial Nerve Stimulation
• Post-mastectomy Surgery and Services
• Prenatal Screening
• Prostatic Urethral Lift (UroLift™ System)
• Proton Beam Therapy
• Radiofrequency Ablation of Uterine Fibroids
• Sacral Nerve Stimulation for Urinary Incontinence
• Sacroiliac Joint Fusion
• Skilled Nursing Facility Level of Care
• Skin Substitutes
• Skysona (elivaldogene autotemcel)
• Speech Generating Devices 
• Speech-Language Therapy Services 
• Spinal Cord Stimulation
• Spine Surgery
• Stereotactic Radiosurgery
• Stretch Devices for Joint Stiffness and Contractures
• Surgery for Obstructive Sleep Apnea
• Tecartus (brexucabtagene autoleucel)
• Transcutaneous Electric Nerve Stimulation (TENS) 
• Transplants, Solid Organ
• Transurethral Waterjet Ablation of Prostate
• Trigger Point Injections
• Urine Drug Testing 
• Vagus Nerve Stimulation
• Varicose Veins of the Lower Extremities 
• Ventricular Assist Devices
• Yescarta (axicabtagene ciloleucel)
• Zolgensma (onasemnogene abeparvovec-xioi)

The InterQual® criteria book view is available by logging into their transparency tool: InterQual medical necessity criteria.