Alliance Health Coverage Criteria
Latest Alliance Health coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Cell & Gene TherapiesNC Medicaid clinical coverage policy for FDA-approved cell and gene therapies, defining coverage criteria, exclusions, prior approval requirements, provider qualifications, CGT Access Model requirements, and claims/billing instructions (partial document: attachments and codes included).All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Community Support Team (CST)Defines Medicaid coverage, eligibility, clinical criteria, and service requirements for Community Support Team (CST) intensive community-based mental health and substance use services for beneficiaries in North Carolina.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Facility-Based Crisis Service for Children and AdolescentsDefines coverage, eligibility, clinical criteria, service components, and operational requirements for facility-based crisis services for Medicaid beneficiaries aged 6–17 in North Carolina.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Geropsychiatric Nursing Facility Services (Clinical Coverage Policy 2B-2)Medicaid coverage and requirements for geropsychiatric units in North Carolina nursing facilities, defining eligibility, clinical criteria, staffing/training, and service provisions for beneficiaries (primarily aged 65+) with severe and persistent mental illness (SPMI).All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-01Deep Brain Stimulation (DBS)Defines North Carolina Medicaid coverage, requirements, and limitations for deep brain stimulation (DBS) procedures for enrolled beneficiaries and providers.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-06-01Thymus Tissue Implantation (RETHYMIC)North Carolina Medicaid clinical coverage policy for single-administration allogeneic processed thymus tissue (RETHYMIC) implantation for immune reconstitution in beneficiaries with congenital athymia, describing medical necessity criteria, exclusions, prior approval, billing and reimbursement guidance.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-04-01Ambulance ServicesDefines coverage, clinical criteria, exclusions, prior approval and billing-related rules for ambulance services (ground and air) for North Carolina Medicaid beneficiaries. Covers emergency and non-emergency medically necessary transports, service definitions, destinations, and limitations.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-04-01Pregnancy Management Program (PMP)Defines the Pregnancy Management Program for NC Medicaid beneficiaries and governing requirements for providers who deliver obstetric services, including coordination with Local Health Departments and criteria for coverage and eligibility.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-02-01Bariatric Surgery Coverage CriteriaDefines coverage, eligibility, and procedural descriptions for bariatric surgery under North Carolina Medicaid (including EPSDT considerations) and who may be affected (adult beneficiaries and case-by-case pediatric EPSDT).All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-07-01Allergy ImmunotherapyDefines NC Medicaid coverage, prior approval expectations, and clinical criteria for allergy immunotherapy and rapid desensitization for beneficiaries enrolled in NC Medicaid.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 1974-01-01Surgery of the Lingual Frenulum (frenectomy/frenotomy/frenuloplasty)North Carolina Medicaid clinical coverage policy that defines medical necessity criteria, prior approval, provider billing and coding, and limitations for surgery of the lingual frenulum (ankyloglossia). Applies statewide to NC Medicaid beneficiaries, includes EPSDT provisions for beneficiaries under 21.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyAllergy testing (skin and serologic)This policy defines medical necessity, coverage criteria, and covered methods for allergy testing (in vivo skin tests and in vitro specific IgE tests) for NC Medicaid beneficiaries and providers performing or ordering these tests.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyAllogeneic Hematopoietic Stem Cell Transplantation for Genetic Diseases and Acquired AnemiasState Medicaid clinical coverage policy governing when allogeneic hematopoietic stem cell transplantation (HSCT) for genetic diseases and acquired anemias is covered for North Carolina Medicaid beneficiaries, including EPSDT considerations for beneficiaries under 21.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyBlepharoplasty and Blepharoptosis (eyelid repair)Medicaid coverage policy governing reconstructive blepharoplasty and blepharoptosis eyelid repair for North Carolina Medicaid beneficiaries, specifying medical necessity criteria, EPSDT exceptions for beneficiaries under 21, and prior approval considerations.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyBone Mass Measurement (BMM/DXA)Coverage criteria, reporting, and special provisions for bone mass measurement (BMM) including DXA, QCT, and ultrasound for NC Medicaid beneficiaries, with pediatric-specific guidance and EPSDT exception language for beneficiaries under 21.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyBreast Imaging ProceduresDefines coverage, medical necessity criteria, prior approval and billing information for breast imaging services (mammography, ultrasound, MRI, ductogram, image-guided biopsy) for NC Medicaid beneficiaries and providers.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyCraniofacial Surgery Coverage CriteriaDefines Medicaid coverage, eligibility, and criteria for craniofacial reconstructive procedures for NC Medicaid beneficiaries, including EPSDT considerations for beneficiaries under 21. Affects providers billing NC Medicaid for craniofacial surgery.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyEndovascular Repair of Aortic AneurysmMedicaid coverage policy for endovascular stent graft repair of abdominal and descending thoracic aortic aneurysms for NC Medicaid beneficiaries, describing medical necessity criteria, exclusions, and prior-approval considerations.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyHIV Tropism Assay (phenotypic)This policy governs coverage of HIV-1 tropism (phenotypic) assays for NC Medicaid beneficiaries, specifying when testing is covered, not covered, and any eligibility and procedural requirements.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyHealth and Behavior InterventionMedicaid coverage policy governing intensive, focused counseling and related interventions for pregnant and postpartum women with serious psychosocial needs in North Carolina Medicaid. It describes eligibility, coverage criteria, EPSDT considerations, and telehealth applicability.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyHeart (Cardiac) TransplantationDefines Medicaid coverage criteria, eligibility, and limitations for pediatric and adult heart transplantation for beneficiaries of the NC Medicaid program.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyHeart‑Lung Transplantation — Medicaid Coverage CriteriaThis policy governs coverage criteria, exclusions, and prior approval requirements for heart‑lung transplant procedures for beneficiaries enrolled in North Carolina Medicaid.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyHematopoietic Stem Cell Transplantation for CLL/SLLClinical coverage criteria for hematopoietic stem cell transplantation (HSCT), including allogeneic HSCT and donor lymphocyte infusion (DLI), for beneficiaries with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) under NC Medicaid.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyHematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)Policy governing coverage, eligibility, and requirements for hematopoietic stem-cell transplantation (HSCT) for treatment of acute lymphoblastic leukemia (ALL) for NC Medicaid beneficiaries.All Alliance Health updates
- Coverage CriteriaClinical/Medical PolicyHyperbaric Oxygenation Therapy (HBO) — NC Medicaid Clinical Coverage PolicyThis policy governs coverage and utilization of hyperbaric oxygen (HBO) therapy for NC Medicaid beneficiaries, specifying covered indications, exclusions, prior approval and EPSDT considerations. It affects providers delivering HBO services to Medicaid enrollees in North Carolina.All Alliance Health updates
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Search Alliance Health 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.
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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.
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