AmeriHealth Caritas Coverage Criteria
- AmeriHealth Caritas prior authorization
- AmeriHealth Caritas contact directory
- All AmeriHealth Caritas policy updates
Latest AmeriHealth Caritas coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Serum Tests for Preeclampsia Risk AssessmentDefines AmeriHealth Caritas coverage stance for serum immunoassays that measure the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio to predict progression to preeclampsia in pregnancy; applies to providers submitting claims to AmeriHealth Caritas.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Home ultraviolet light therapy equipment for skin conditionsDefines medical necessity and coverage criteria for home narrowband UVB phototherapy devices for photoresponsive skin conditions and excludes home UVA/PUVA and non-therapeutic uses; applies to AmeriHealth Caritas members and their treating clinicians.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-20Radiofrequency ablation of genicular nerves for knee painThis policy governs coverage determinations for diagnostic genicular nerve block and radiofrequency ablation (RFA) of genicular nerves to treat chronic knee pain, including osteoarthritis and pain after total knee arthroplasty, for AmeriHealth Caritas members and providers making coverage requests.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-02Digestive enzyme cartridge (RELiZORB) coverage criteriaPolicy governing medical necessity and coverage of the in-line immobilized lipase digestive enzyme cartridge (RELiZORB) for members with cystic fibrosis and confirmed exocrine pancreatic insufficiency receiving enteral nutrition and pancreatic enzyme replacement therapy.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-20Bronchial Thermoplasty for Severe AsthmaDefines medical necessity criteria and coverage stance for bronchial thermoplasty (Alair) in adults with severe, persistent asthma and describes contraindications and background evidence; applies to AmeriHealth Caritas coverage determinations.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Abdominoplasty (tummy tuck) coverageDefines AmeriHealth Caritas' coverage stance on abdominoplasty, including when it is considered investigational/not medically necessary and alternative non-surgical management; intended for providers making coverage requests for members.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-20Transcatheter pulmonary valve replacementDefines medical necessity and coverage criteria for transcatheter pulmonary valve replacement (including Melody, Harmony, Edwards SAPIEN 3 with Alterra) for members with pulmonary valve stenosis or insufficiency and related right ventricular outflow tract dysfunction.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Skin Substitutes for Chronic WoundsDefines medical necessity and coverage criteria for cellular and acellular skin substitute products used as adjunctive therapy for chronic cutaneous wounds and select acute thermal burns for AmeriHealth Caritas members.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-01Endovenous stentsCoverage criteria and evidence summary for placement of endovenous (venous) stents for management of chronic venous disease and other venous obstructions; intended for AmeriHealth Caritas coverage determinations and providers seeking authorization guidance.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Dermabrasion and chemical peelDefines AmeriHealth Caritas coverage stance and clinical criteria for dermabrasion and chemical peel procedures, primarily for treatment of pre-cancerous actinic keratosis and other pre-malignant skin conditions; intended for providers and coverage reviewers.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Nonpharmacologic treatments for chronic vertigoDefines AmeriHealth Caritas coverage stance for nonpharmacologic treatments for chronic vertigo (including particle repositioning maneuvers, vestibular rehabilitation, dynamic posturography, and transtympanic micropressure) and the clinical criteria and limitations that apply to members and providers.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Peristeen® anal irrigation systemMedical necessity and coverage criteria for the Peristeen transanal irrigation system for bowel management, governing AmeriHealth Caritas benefit determinations for covered members.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-05-20AcupunctureThis policy governs medical necessity and coverage criteria for acupuncture services provided to AmeriHealth Caritas members, specifying covered indications, limitations, and practitioner qualifications.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-20Biofeedback for chronic painDefines coverage stance for biofeedback interventions for non-malignant musculoskeletal pain and primary headache disorders and member/provider requirements for coverage.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-06Breast PumpsCoverage and medical necessity guidance for provision of manual, personal-use electric, and hospital-grade electric breast pumps and initial replacement supplies for lactating parents.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Peroral endoscopic myotomy (POEM)This policy governs medical necessity and coverage criteria for peroral endoscopic myotomy (POEM) procedures for esophageal achalasia and gastric POEM for refractory gastroparesis, including contraindications, alternative services, and investigational indications, for AmeriHealth Caritas members.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-01Prescription digital therapeutics for contraceptionDefines coverage criteria, limitations, and clinical context for FDA-cleared prescription digital therapeutics (Natural Cycles and Clue Birth Control) used as fertility-awareness methods of contraception for eligible female members.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-01Video head impulse testingThis policy governs medical necessity and coverage of video head impulse testing (vHIT) for evaluation of semicircular canal and vestibular function, affecting AmeriHealth Caritas members and providers requesting coverage for vestibular diagnostic testing.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-02-01Gastroparesis EvaluationsDefines medical necessity criteria and coverage stance for diagnostic testing to document delayed gastric emptying (scintigraphy, carbon-13 breath test, wireless motility capsule) for members with suspected gastroparesis and who have been evaluated by a gastroenterologist.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-08-01Prostatic urethral lift (UroLift) for benign prostatic hyperplasiaDefines AmeriHealth Caritas coverage and medical necessity criteria for prostatic urethral lift (UroLift) to treat lower urinary tract symptoms from benign prostatic hyperplasia; applies to plan-covered members and providers submitting requests to AmeriHealth Caritas.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-01Drug-eluting sinus implantsDefines medical necessity and coverage criteria for drug-eluting sinus implants (e.g., PROPEL, Sinuva) following endoscopic sinus surgery for chronic rhinosinusitis for AmeriHealth Caritas members.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-05-20Behavioral health weight management interventions for children with increased body mass index screeningsDefines coverage for intensive behavioral health and lifestyle treatment programs for children and adolescents with elevated body mass index (BMI), describing eligibility, program characteristics, and limitations for AmeriHealth Caritas members.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-03-01Sacral nerve modulation/stimulationDefines AmeriHealth Caritas coverage stance and medical necessity criteria for sacral nerve stimulation (sacral neuromodulation) for adults and discusses investigational uses and contraindications; intended for clinicians and utilization reviewers determining coverage.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-02-01Shoe Lifts for Leg Length DiscrepancyDefines medical necessity criteria and coverage stance for internal and external shoe lifts used to treat leg length discrepancy for AmeriHealth Caritas members.All AmeriHealth Caritas updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-09-01Balloon dilation of the Eustachian tubeDefines coverage criteria, limitations, and required diagnostics for transnasal balloon dilation of the Eustachian tube for AmeriHealth Caritas members; applies to clinical coverage determinations for providers performing the procedure.All AmeriHealth Caritas updates
1–25 of 41
1 / 2
Tool Description
Search AmeriHealth Caritas 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.
Coverage Criteria by Payer
Go deeper
Explore OpenPayer Data
Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Prior Authorization LookupSearch payer prior authorization policies by drug, procedure, or policy name.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.