What does medically necessary mean?

Medically necessary means a service is appropriate for the diagnosis and consistent with accepted standards of medicine, as judged against the payer's published criteria. Each payer defines it through its own coverage criteria, so the same service can be medically necessary under one plan and denied under another.

How are coverage criteria different from prior authorization?

Coverage criteria define what a payer requires clinically before it covers a service. Prior authorization is the process of getting approval in advance, and the reviewer checks the request against those criteria. Some services have coverage criteria without requiring prior authorization, and the claim is reviewed against them after submission instead.

How do I find a payer's coverage criteria for a drug or procedure?

Search the drug, procedure, or service name and filter by the patient's payer, or open the payer's page to browse every criteria policy on file. Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.

Coverage Criteria by Payer

Top payers by coverage criteria policies25

Neighborhood Health Plan Of Rhode Island2,392 coverage criteria policiesUpdated 2026-07-01Brivaracetam (Briviact) coverage criteria for partial-onset seizuresEff. 2026-07-01Criteria for initial approval, continuation, quantity limits, and coverage duration for brivaracetam (Briviact) for members (Medicaid scope) beginning 2026-07-01.All Neighborhood Health Plan Of Rhode Island policy updates
UnitedHealthcare1,999 coverage criteria policiesUpdated 2026-08-01Kebilidi (eladocagene exuparvovec-tneq) — Coverage Criteria for AADC DeficiencyEff. 2026-08-01This policy governs medical benefit coverage criteria for Kebilidi (a one-time gene therapy) to treat aromatic L‑amino acid decarboxylase (AADC) deficiency and applies to UnitedHealthcare members except where state-specific exceptions are noted.All UnitedHealthcare policy updates
Cigna1,499 coverage criteria policiesUpdated 2026-08-15Abortion — Treatment of Complications and Coverage CriteriaEff. 2026-08-08This administrative policy describes Cigna coverage for abortion services and medically necessary treatment of complications following an abortion under standard Cigna benefit plans and explains relevant definitions and coding. It applies to providers submitting claims to Cigna and is governed by the terms of the applicable benefit plan and state regulations.All Cigna policy updates
Centene1,273 coverage criteria policiesUpdated 2026-08-01Multiple Sleep Latency Testing (MSLT) Coverage CriteriaEff. 2026-08-01Defines medical necessity criteria and coding guidance for Multiple Sleep Latency Testing (MSLT) for members/enrollees age two years and older, and requirements for repeat testing. Applies to health plans affiliated with Centene Corporation.All Centene policy updates
Premera Bluecross963 coverage criteria policiesUpdated 2026-09-04Testosterone laboratory testing and measurement (coverage criteria)Eff. 2026-09-04Defines when serum total, free, bioavailable testosterone and related hormone tests (e.g., SHBG, albumin, estradiol, DHT) are reimbursable, not reimbursable, and provides analytical/testing guidance; applies to Premera Bluecross coverage determinations.All Premera Bluecross policy updates
Colorado Rocky Mountain Health Plans939 coverage criteria policiesUpdated 2026-09-01Vedolizumab (Entyvio) intravenous infusion — coverage and medical necessity criteriaEff. 2026-08-01This policy governs medical-benefit coverage and medical necessity criteria for vedolizumab (Entyvio) intravenous infusion for Crohn's disease, ulcerative colitis, immune checkpoint inhibitor-related toxicities, and GI acute graft-versus-host disease for Colorado Rocky Mountain Health Plans members; the subcutaneous formulation is handled under the pharmacy benefit.All Colorado Rocky Mountain Health Plans policy updates
Mhn873 coverage criteria policiesUpdated 2026-08-01Transitional Rent (Community Supports) — Coverage CriteriaEff. 2026-01-01Defines eligibility, provider and plan responsibilities, settings, documentation, authorization processes, and limits for Transitional Rent rental assistance as a Medi‑Cal Community Supports service affecting members and contracted providers in the plan network.All Mhn policy updates
Ambetter Georgia492 coverage criteria policiesUpdated 2026-08-26Multiple Sleep Latency Testing (MSLT) Coverage CriteriaEff. 2026-08-01Defines medical necessity criteria, coding, and repeat-testing indications for Multiple Sleep Latency Testing (MSLT) for members/enrollees of the health plan; applies to clinical providers ordering or performing MSLT.All Ambetter Georgia policy updates
Blue Cross Blue Shield - North Carolina482 coverage criteria policiesUpdated 2026-08-01Evinacumab-dgnb (Evkeeza) IV infusion — Coverage Criteria for Homozygous Familial HypercholesterolemiaEff. 2026-08-01Defines medical necessity, site-of-care, authorization, and dosing/units for evinacumab-dgnb (Evkeeza) IV infusion for patients aged ≥1 year with homozygous familial hypercholesterolemia (HoFH); applies to Blue Cross NC membership and providers requesting coverage.All Blue Cross Blue Shield - North Carolina policy updates
Health Net466 coverage criteria policiesUpdated 2026-08-01Asthma Remediation Community Support — Authorization and Coverage CriteriaEff. 2025-12-16Governs authorization and provision of in‑home asthma remediation supplies and physical modifications for Medi‑Cal members in California, describing eligibility, required documentation, limits, and provider requirements for Health Net‑managed services.All Health Net policy updates
Blue Cross Blue Shield - Iowa426 coverage criteria policiesUpdated 2026-08-15Kineret (anakinra) — Coverage CriteriaEff. 2026-08-14Defines prior-authorization, documentation, prescriber specialty, and medical necessity criteria for Kineret (anakinra) for FDA-approved and compendial indications for Blue Cross Blue Shield - Iowa members.All Blue Cross Blue Shield - Iowa policy updates
Anthem403 coverage criteria policiesUpdated 2026-06-01Atezolizumab (Tecentriq, Tecentriq Hybreza) coverage criteriaEff. 2026-06-01Clinical prior authorization and coverage criteria for Tecentriq (atezolizumab) and Tecentriq Hybreza across multiple oncology indications, specifying clinical scenarios, combinations, and restrictions for Anthem members.All Anthem policy updates
AvMed382 coverage criteria policiesUpdated 2023-07-26Prior authorization and coverage criteria for Vyleesi (bremelanotide)Eff. 2023-07-26This document is a prior authorization/step-edit request form and clinical criteria for coverage of Vyleesi (bremelanotide) for members of AvMed. It governs prescriber submission requirements and clinical eligibility for Vyleesi therapy.All AvMed policy updates
Blue Cross Blue Shield - Rhode Island361 coverage criteria policiesUpdated 2026-10-01Biomarker Testing / Genetic & Molecular Testing Coverage CriteriaEff. 2026-08-01Governs state-mandated coverage, medical necessity, and prior authorization requirements for biomarker and genetic/molecular tests for BCBSRI Commercial Products and Medicare Advantage Plans.All Blue Cross Blue Shield - Rhode Island policy updates
Blue Cross Blue Shield - Tennessee360 coverage criteria policiesUpdated 2026-09-01Secukinumab (Cosentyx) — Coverage CriteriaEff. 2026-09-01Medical policy governing prior authorization, coverage criteria, and documentation requirements for secukinumab (Cosentyx) for FDA‑approved indications and compendial uses for Blue Cross Blue Shield of Tennessee members.All Blue Cross Blue Shield - Tennessee policy updates
EmblemHealth317 coverage criteria policiesUpdated 2026-05-08Medical Technologies Database — Investigational, Unproven, HDE, and Transplant Case Management Coverage CriteriaEff. 2026-05-01This document lists medical technologies, devices, and procedures that EmblemHealth considers investigational, unproven, or subject to special handling (including HDE and FEHB notes) and describes program-level transplant case management; it affects providers submitting precertification/coverage requests for EmblemHealth members, including transplant program referrals.All EmblemHealth policy updates
Blue Cross Blue Shield - Massachusetts298 coverage criteria policiesUpdated 2026-06-01Neurology & Neurosurgery — Coverage Criteria and Policy Updates (Spine Fusion, Neuromodulation, DBS, MEG)Eff. 2026-04-01Summarizes new and revised neurology/neurosurgery medical policies, investigational determinations, coding and prior authorization updates, and changes to InterQual applicability that affect BCBSMA providers and prior authorization processes.All Blue Cross Blue Shield - Massachusetts policy updates
Mass General Brigham Health Plan286 coverage criteria policiesUpdated 2026-08-01Emrelis (telisotuzumab vedotin‑tllv) — Coverage CriteriaEff. 2026-07-01Defines prior authorization requirements and medical benefit coverage criteria for Emrelis (telisotuzumab vedotin-tllv) for adults with locally advanced or metastatic non‑squamous non‑small cell lung cancer with high c‑Met overexpression; applies to Mass General Brigham Health Plan medical benefit members including MassHealth UPPL.All Mass General Brigham Health Plan policy updates
Viva Health277 coverage criteria policiesUpdated 2026-07-01Evenity (romosozumab-aqqg) (Subcutaneous) — Coverage CriteriaEff. 2026-07-01Defines prior authorization, dosing limits, eligibility, and billing/coding for Evenity (romosozumab-aqqg) for treatment of osteoporosis, primarily in postmenopausal women, for Viva Health members.All Viva Health policy updates
Aetna243 coverage criteria policiesUpdated 2021-12-01Etanercept (Enbrel) — Coverage Criteria and Prior AuthorizationEff. 1999-02-10Clinical coverage and prior authorization requirements for etanercept (Enbrel) including indications, prescriber specialty requirements, initial and continuation criteria, dosing notes, and experimental/investigational exclusions for Aetna members.All Aetna policy updates
Capital Bluecross241 coverage criteria policiesUpdated 2026-07-01Temporomandibular Disorder (TMD) — Coverage CriteriaEff. 2026-07-01Clinical coverage policy for diagnostic, nonsurgical, and surgical management of temporomandibular disorder (TMD); specifies medically necessary versus investigational procedures and cross-references related policies.All Capital Bluecross policy updates
Sierra Health And Life241 coverage criteria policiesUpdated 2026-08-01Orthognathic (Jaw) Surgery — Coverage CriteriaEff. 2026-05-01Defines clinical coverage criteria and coding references for reconstructive orthognathic (jaw) surgery for UnitedHealthcare Commercial and Individual Exchange benefit plans; applies to members with facial skeletal deformities and associated functional impairment.All Sierra Health And Life policy updates
Eocco226 coverage criteria policiesUpdated 2026-07-09Cinqair (reslizumab) (Intravenous) — Coverage CriteriaEff. 2026-07-01Criteria, dosing, coding, and prior authorization rules governing coverage of intravenous reslizumab (Cinqair) for members of the plan, including initial and renewal authorization requirements and concomitant therapy prohibitions.All Eocco policy updates
Meridian215 coverage criteria policiesUpdated 2026-09-01Finerenone (Kerendia) — Coverage Criteria for CKD with Type 2 DiabetesEff. 2025-08-01Defines medical necessity and prior authorization criteria for finerenone (Kerendia) for adult members with chronic kidney disease associated with type 2 diabetes under Meridian (Medicaid) lines of business.All Meridian policy updates
CareSource198 coverage criteria policiesUpdated 2026-08-01Adzynma (ADAMTS13, recombinant-krhn) — Medical prior authorization and coverage criteria for congenital TTPEff. 2026-07-01Defines medical prior authorization and coverage criteria for Adzynma used as prophylactic or on‑demand enzyme replacement therapy in adult and pediatric patients with congenital thrombotic thrombocytopenic purpura (cTTP) for CareSource Arkansas PASSE.All CareSource policy updates

Top 25 payers · 20,190 policies

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Tool Description

Search payer 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.

Tool Description

Search payer coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.

Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.

FAQ