Eye Procedures, Reconstructive Form

Harvard Pilgrim HealthCare Medical Policy

Reconstructive Eye Procedures STRIDEsm (HMO) MEDICARE ADVANTAGE

Subject: Reconstructive Eye Procedures

Authorization: Prior authorization from Harvard Pilgrim StrideSM (HMO) Medicare Advantage is required for all reconstructive and restorative eye procedures.

Policy and Coverage Criteria: Harvard Pilgrim Health Care (HPHC) utilizes Centers for Medicare and Medicaid Services (CMS) guidelines and applicable National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) for medical necessity determination.