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
• Adult Day Health - NaviCare only, effective January 1, 2026
• Adult Foster Care - Navicare only, effective January 1, 2026
• Allogeneic Stem Cell Transplantation
• Ambulatory Cardiac Monitoring
• Anterior Segment Optical Coherence Tomography  
• Arthroscopic Lavage and Debridement for Osteoarthritis of the Knee (formerly Arthroscopy for Osteoarthritis of the Knee)
• Autologous Chondrocyte Implantation 
• Autologous Stem Cell Transplantation
• Balloon Sinus Ostial Dilation
• Bariatric Surgery
• Bone-Anchored Hearing Aids 
• Bronchial Thermoplasty
• Capsule Endoscopy
• Cochlear Implants
• Community-based LTSS Services - NaviCare only, effective January 1, 2026
• Corneal and Scleral Contact Lenses 
• Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Systems
• Cosmetic, Reconstructive, and Restorative Services
• Day Habilitation - NaviCare only, effective January 1, 2026
• Deep Brain Stimulation
• Durable Medical Equipment
• Excimer Laser Skin Therapy
• Fecal Calprotectin Testing
• Fecal Microbiota Transplant
• Gender Affirmation Services
• Genetic Testing
• Group Adult Foster Care - NaviCare only, effective January 1, 2026
• Hearing Aids for Community Care Plan Members 21 Years of Age or Younger
• Hip Arthroscopy of Femoroacetabular Impingement 
• Home Health Care Services
• 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
• Oral Appliances for Obstructive Sleep Apnea
• Orthognathic Surgery
• Peripheral Nerve Blocks
• Personal Care Attendant - NaviCare only, effective January 1, 2026
• 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-Language Therapy Services 
• Spinal Cord Stimulation
• Spine Surgery
• Stereotactic Radiosurgery
• 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.