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ACG

​

h.o.l.M.E.S.

Automated Clinical Guidelines

Point             Health

Harvard Pilgrim Health Care

HP 2024 Stride PA Criteria V7 1-1-24
HP 2024 Stride PA Criteria V8 2-1-24

Mass Health

 Oncology Agents
Stride BasicRx
Stride ValueRx
Stride ValueRxPlus
Stride ChoiceRx
Stride BasicRx
Stride ValueRx
Stride ValueRxPlus
Stride ChoiceRx
Antineoplastics

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Tufts Commercial
Tuft Health Direct
Chimeric Antigen Receptor (CAR) T Immunotherapies
Dermatologic Agents
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors
Weight Loss Medications

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Tufts Commercial Tufts Health Direct

Point32Health

Blepharoplasty, Blepharoptosis
& Brow Lift
Anterior Vertebral Body Tethering
Anti-Obesity Agents
Humira (adalimumab)
Endoscopic Sinus Surgeries
Inpatient Setting for Elective Total Joint Arthroplasty
Surgical Treatments for Lymphedema & Lipedema
Treatment of Varicose Veins of the Lower Extremities
Interventional Cardiology
Applied Behavioral Analysis (ABA) Therapy and Habilitative Services for Autism Spectrum Disorders
Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, &  Molecular Profiling
Fecal Microbial Transplant (FMT) for Clostridium Difficile Infection
Mohs
Micrographic Surgery (MMS)
Transcatheter Mitral Valve Repair (TMVR)
Temporary Total Artificial Heart System Bridge-to-Transplant
Upper Gastrointestinal Endoscopy (Esophagogastro-duodenoscopy, EGD)
Upper Limb Prostheses
Urine Drug Testing
UVB Home Units for Skin Disease
Vitamin B12 Screening & Testing
Vitamin D Screening & Testing
Cardiac Event Monitors
Cardiovascular Disease Risk Tests
Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing
Cell-free DNA Testing for the Management of Cancer
Chromosomal Microarray Analysis (CMA)
Comprehensive Genomic Profiling with FoundationOne CDx or FoundationOne Liquid CDx
Continuous Glucose Monitoring and Diabetes Management Devices
COVID-19 Antibody (Serological) Testing
COVID-19 Monoclonal Antibody Therapy
Early Intensive Behavioral Intervention (EIBI)
Family Stabilization Treatment (FST) Criteria for Behavioral Health Services
Custom Fabricated Oral Appliances for Obstructive Sleep Apnea (OSA)
Hereditary Cancer Testing 
Home Care Skilled Nursing Services
Gender Affirming Services
Genetic Testing for Inherited Diseases
Hematopoietic Stem-Cell Transplantation (HSCT)
Hyperbaric Oxygen Treatment (HBO)
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Pharmaco-genomic Testing
Polygenic Risk Scores
Prenatal Testing using cell-free DNA
Remote Patient Monitoring
Somatic Tumor Testing
Allergy Testing and Immunotherapy
Balloon Dilation of the Eustachian Tube
Breast Pumps
Cochlear Implants
Implantable Pulmonary Artery Pressure Devices (CardioMEMS HF)
Inpatient Acute Level of Care (Medical/Surgical)
Intensity-Modulated Radiation Therapy (IMRT)
Solid Organ Transplant – Heart
Solid Organ Transplant: Intestinal (Small Bowel, Simultaneous Small Bowel-Liver) and Multivisceral
Solid Organ Transplant – Kidney
Solid Organ Transplant - Liver
Solid Organ Transplant: Lung
Solid Organ Transplant: Pancreas-Kidney Transplant, Pancreas Transplant, Pancreas Islet Cell Transplant
Subcutaneous Implantable Cardioverter Defibrillator (S-ICD)
Transcervical Radiofrequency Ablation of Uterine Fibroids
Tumor Treating Fields
Artificial Cervical Disc Replacement
Assisted Reproductive Technology Services
Bariatric Surgery
Behavioral Health Inpatient & 24 Hour Level of Care Determinations
Behavioral Health Level of Care for Non- 24 Hour/Intermediate/Diversionary Services
Cervical Spine Surgery
Cholecystectomy, Laparoscopic
Clinical Review of Dental Services
Clinical Trials: Routine Costs
Donor Breast Milk
Family Support & Training (FS&T)
Fertility Services
Home Health Care Services
Hysterectomy, Certain Electives
Implantable Neurostimulators
In-Home Behavioral Services (IHBS)
In-Home Therapy Services (IHTS)
Inpatient Setting for Elective Total Joint Arthroplasty;
Hip & Knee
Intraoperative Neurophysiological Monitoring
Interventional Pain Management for Back Pain
Knee Surgery
Lower Limb Prostheses
Lumbar Spine Surgeries
Medical Transportation
Mobile Cardiac Outpatient Telemetry (MCOT)
Mobile Crisis Intervention (MCI) for Youths
Molecular Diagnostic Management
Neuropsycho-logical Testing & Assessment
Noncovered Investigational Services
Oncology
Oral Formula & Enteral Nutrition
Orthognathic Surgery for Severe Oral- Maxillofacial Functional Disorders
Osteogenesis Stimulators
Out-of-Network Coverage at the In-Network Level of Benefits
Outpatient Diagnostic Imaging
Private Duty Nursing in the Home
Outpatient Psychotherapy
Outpatient Pulmonary Rehabilitation
Percutaneous Left Atrial Appendage Closure to ReduceStroke Risk in Patients with Atrial Fibrillation (Watchman Device)
Percutaneous Tibial Nerve Stimulation (PTNS)
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia (POEM)
Procedures for the Treatment of Benign Prostatic Hypertrophy (BPH) 
Procedures for the Treatment of Symptomatic Varicose Veins 
Positive Airway Pressure Devices for Sleep Apnea
Power Operated Vehicles (POVs)
Power Wheelchairs
Proton Beam Therapy
Psychological Testing and Assessment 
Reconstructive & Cosmetic Surgery 
Removal of Benign Skin Lesions
Shoulder Surgery 
Sleep Studies
Speech, Hearing, & Language Services
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Stereotactic Radiosurgery
& Stereotactic Body Radiotherapy
Surgical Procedures for the Treatment of Obstructive Sleep Apnea
Vertebroplasty
& Kyphoplasty 
Targeted Case Management Services
Temporoman-dibular Joint (TMJ) Disorder Treatment 
Therapeutic Mentoring (TM)
Transcranial Magnetic Stimulation (rTMS)
Video Capsule Endoscopy 
Spine Surgery
Harvard Pilgrim Health Care Stride (HMO) 2024 Formulary
Hip Surgery
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