Ambetter Georgia Coverage Criteria
Latest Ambetter Georgia coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-26Percutaneous Left Atrial Appendage Closure Device for Stroke PreventionDefines medical necessity criteria and coding implications for FDA‑approved percutaneous LAA occlusion devices (WATCHMAN, WATCHMAN FLX, Amplatzer Amulet) for stroke prevention in adults with non‑valvular atrial fibrillation who are candidates for the procedure.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Air AmbulanceMedical necessity criteria and coverage guidance for fixed-wing and rotary-wing air ambulance transport for Ambetter Georgia members; governs when air transport is considered medically necessary or not and lists relevant billing codes.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Allogeneic Hematopoietic Progenitor Cell TherapyDefines medical necessity criteria for non-Medicare Ambetter Georgia plans for two FDA‑approved allogeneic hematopoietic progenitor cell therapies (Omisirge/omidubicel and RegeneCyte/HPC cord blood) and summarizes background, evidence, and coding implications. Affects providers requesting coverage for these therapies for eligible members/enrollees.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Drugs of Abuse: Definitive TestingRules for outpatient definitive/confirmatory drug testing (urine and other sources) including medical necessity criteria, limits on number of drug classes, and exclusions for administrative/screening uses that affect providers ordering and billing for Ambetter Georgia members.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Immobilized Lipase Cartridges (RELiZORB)Medical necessity criteria for use of RELiZORB immobilized lipase cartridges with enteral feeding for members of Ambetter Georgia / Centene-affiliated health plans.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Liposuction for LipedemaThis policy governs medical necessity criteria and coverage stance for liposuction as a treatment for lipedema for members of Ambetter Georgia / Centene-affiliated health plans.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Liposuction for LipedemaThis policy governs medical necessity criteria and coverage stance for liposuction as a treatment for lipedema for members of Ambetter Georgia (Centene-affiliated health plans). It affects providers requesting authorization for liposuction to treat lipedema.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Multiple Sleep Latency Testing (MSLT) Coverage CriteriaDefines 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 updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Pediatric Oral Function TherapyMedical necessity policy for initial and continuation pediatric oral function (feeding and swallowing) therapy for children, describing clinical criteria and documentation requirements for Ambetter Georgia members.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Pulmonary Function Testing (Clinical Policy)Medical necessity criteria and coding guidance for pulmonary function tests (PFTs) for members aged three years and older under Ambetter Georgia.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Repair of Nasal Valve CompromiseMedical necessity guidelines for surgical and device-based treatments of nasal valve compromise (NVC) for members of Ambetter Georgia health plans; describes covered procedures, not medically necessary procedures, and supporting clinical and coding information.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Therapeutic Utilization of Inhaled Nitric OxideDefines medical necessity, continuation, and non‑coverage criteria for initiation and ongoing use of inhaled nitric oxide therapy across neonatal, pediatric, and adult settings for members of Ambetter Georgia.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Pancreas TransplantationMedical necessity and coding criteria governing coverage for pancreas transplantation (PTA, SPK, PAK), autologous islet autotransplantation, retransplantation, and exclusions for Ambetter Georgia members.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Assisted Reproductive TechnologyDefines medical necessity, coverage criteria, and exclusions for assisted reproductive technologies (IVF, IUI, ICSI, donor gametes, cryopreservation, GIFT/ZIFT, TESE/MESA, etc.) for Ambetter Georgia members when infertility benefits are included in the member's benefit plan.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Clinical Policy: Lung TransplantationDefines medical necessity criteria, candidate evaluation, contraindications, and coding for lung transplantation for Ambetter Georgia members (non-Medicare noted in revisions). Applies to providers submitting transplant-related requests and claims.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Cochlear ImplantsMedical necessity guidelines for unilateral and bilateral cochlear implant placement and coverage for Ambetter Georgia members/enrollees, aligned with Washington State Health Care Authority assessments and billing guidelines.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive-Compulsive DisorderMedical necessity criteria and coverage stance for deep transcranial magnetic stimulation (dTMS) to treat adults with obsessive-compulsive disorder (OCD) for members of Ambetter Georgia (Centene-affiliated plans).All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Donor Lymphocyte Infusion (DLI) Coverage CriteriaMedical necessity and coverage criteria for donor lymphocyte infusion after allogeneic hematopoietic stem cell transplantation for relapsed or high-risk hematologic malignancies applicable to Ambetter Georgia non‑Medicare plans and Centene-affiliated non‑Medicare plans.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay — Coverage CriteriaDefines medical necessity criteria and coding guidance for genetic testing (e.g., chromosomal microarray, gene-specific tests, panels, methylation and UPD analysis) used to evaluate multisystem inherited disorders, intellectual disability, developmental delay, and related conditions; applies to providers submitting claims to Ambetter Georgia/Coordinated Care as of the effective date.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Heart‑lung transplant coverage criteriaMedical necessity criteria and coverage guidance for combined heart‑lung transplantation for Ambetter Georgia members, describing indications, contraindications, and coding implications for providers and transplant centers.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Home VentilatorsMedical necessity criteria for provision and continued use of home ventilators (noninvasive and invasive) for non‑Medicare Ambetter Georgia plans; defines indications, continuation, overlap-syndrome review, and backup/second ventilator situations.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Home VentilatorsMedical necessity criteria and coverage rules for initial and ongoing home use of noninvasive and invasive ventilators for non‑Medicare health plans affiliated with Centene (Ambetter Georgia). Affects providers requesting coverage for home ventilators and related devices.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Intensity Modulated Radiation TherapyMedical necessity criteria and coding guidance for use of intensity-modulated radiotherapy (IMRT) for cancer treatment; intended for providers and claim reviewers administering Ambetter Georgia benefits.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Pediatric Kidney TransplantMedical necessity criteria and coding guidance for pediatric (<18 years) kidney transplantation for non‑Medicare Ambetter Georgia members/enrollees, based on KDIGO and OPTN guidance.All Ambetter Georgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Ultrasound in Pregnancy (Clinical Policy)Medical necessity criteria and coding guidance for ultrasound use during pregnancy for Ambetter Georgia members and providers rendering obstetric imaging.All Ambetter Georgia updates
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Search Ambetter Georgia 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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