Baylor Scott & White Health Plan Coverage Criteria
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Latest Baylor Scott & White Health Plan coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Inhaled Nitric Oxide (iNO) in Preterm/Neonatal Infants — Medical Coverage PolicyClinical coverage policy governing use of inhaled nitric oxide for newborns and infants (including perioperative pediatric use) under Baylor Scott & White Health Plan; applies across lines of business and informs medical necessity determinations and retrospective review processes.All Baylor Scott & White Health Plan updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Transoral Fundoplication (TIF 2.0) — Medical Necessity and Coverage CriteriaDefines medical necessity, inclusion and exclusion criteria, coding guidance, and authorization requirements for transoral incisionless fundoplication (EsophyX®/TIF 2.0) for Baylor Scott & White Health Plan members across lines of business.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Cancer Chemotherapy / Therapy GuidelinesDefines medical necessity and coverage criteria for oncology medications and select related therapies for Baylor Scott & White Health Plan members, including criteria for FDA-labeled and compendium-supported uses and requirements for continuation and prior authorization.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Endoscopic Surgery for CraniosynostosisDefines medical necessity and prior authorization requirements for endoscopic (endoscopy-assisted) surgical repair of craniosynostosis in infants, and lists applicable procedure and diagnosis codes. Applies to Baylor Scott & White Health Plan lines of business and referenced Medicare/Medicaid guidance.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Exagamglogene autotemcel (Casgevy) coverage and prior authorizationMedical coverage policy governing prior authorization and medical necessity criteria for exagamglogene autotemcel (Casgevy) for treatment of Sickle Cell Disease (SCD) and Transfusion-dependent β-thalassemia (TDT) for Baylor Scott & White Health Plan members.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Seizure Disorders: Invasive Treatments (Epilepsy Surgery)Criteria and coverage stance for invasive epilepsy treatments (resective surgery, LITT, neurostimulation including DBS, RNS, VNS) for Baylor Scott & White Health Plan members; applies across lines of business and to Medicare/Medicaid when local NCD/LCD or TMPPM do not provide criteria.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Transcatheter Valve Replacement or RepairDefines medical necessity, prior authorization, and coding guidance for transcatheter aortic, mitral and pulmonary valve replacement or repair for Baylor Scott & White Health Plan members.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Digital Cognitive Behavioral TherapyDefines medical necessity and coverage criteria for practitioner‑prescribed digital cognitive or behavioral therapy applications (mobile software applications / prescription digital therapeutics) and lists evaluated products; applies to Baylor Scott & White Health Plan lines of business and to Medicare/Medicaid where plan-specific rules do not supersede.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Genetic (Genomic) Testing Coverage CriteriaDefines medical necessity, prior authorization, documentation, and coverage criteria for genetic and genomic testing for members of Baylor Scott & White Health Plan and affiliated lines of business.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Keratoconus and Medical Contact LensesDefines medical necessity and coverage criteria for keratoconus, corneal disorders, therapeutic contact lenses (including corneal bandages), and collagen cross-linking; applies to Baylor Scott & White Health Plan lines of business and members in applicable jurisdictions.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Laser Treatment of Skin LesionsDefines medical necessity, prior authorization, and coverage criteria for laser therapy for various skin lesions for Baylor Scott & White Health Plan members; applies across lines of business and references Medicare and Texas Medicaid guidance where applicable.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Medications Covered Under Medical Insurance PolicyDefines medical necessity, prior authorization expectations, and general coverage criteria for medications administered by a medical professional when no more specific medical policy exists; applies to Baylor Scott & White Health Plan lines of business and related plan types.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Obecabtagene autoleucel (Aucatzyl) CAR-T therapy coverage criteriaMedical necessity and coverage criteria for the use of obecabtagene autoleucel (Aucatzyl) in adults with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL) for Baylor Scott & White Health Plan members.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Obstructive Sleep Apnea: Diagnosis and TreatmentDefines medical necessity criteria for diagnostic testing (laboratory and home PSG), indications for treatment modalities (PAP, oral appliances, surgery, hypoglossal nerve stimulation), follow-up testing, exclusions of specific therapies/devices, and applicable billing codes for obstructive sleep apnea across lines of business.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Custodial Care (Coverage Criteria)Defines custodial (non-skilled) care, explains coverage stance across lines of business, and provides guidance for Texas Medicaid use of TMPPM criteria. Affects providers seeking reimbursement from Baylor Scott & White Health Plan.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Fetal SurgeryThis policy governs coverage and medical necessity criteria for in-utero fetal surgical procedures for Baylor Scott & White Health Plan members across lines of business; providers should also consult member-specific Evidence of Coverage or Summary Plan Description for benefit details.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Alglucosidase alfa (Lumizyme) for Pompe diseaseDefines prior authorization, medical necessity criteria, and renewal criteria for coverage of alglucosidase alfa (Lumizyme) for treatment of infantile- and late-onset Pompe disease for Baylor Scott & White Health Plan members.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Balloon Dilation of the Eustachian TubeMedical coverage policy governing when Baylor Scott & White Health Plan considers balloon dilation of the Eustachian tube (BDET) medically necessary or investigational for members; applies to providers submitting claims and seeking prior authorization.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Cancer Chemotherapy / Therapy GuidelinesDefines medical necessity criteria, documentation, and limits for oncology medications and chemotherapy regimens for Baylor Scott & White Health Plan members; applies to all lines of business unless otherwise indicated.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Cardiac MonitoringClinical coverage criteria and coding guidance for outpatient cardiac monitoring services (external loop recorders, mobile cardiovascular telemetry, implantable loop recorders, CardioMEMS and related devices) for Baylor Scott & White Health Plan members.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Durable Medical Equipment and Over the Limit SuppliesGoverns medical necessity and coverage considerations for durable medical equipment and requests for supplies that exceed plan limits for Baylor Scott & White Health Plan members, including Medicare and Medicaid considerations where applicable.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Elivaldogene autotemcel (Skysona) gene therapy for childhood cerebral adrenoleukodystrophy (CALD)Defines clinical coverage criteria, prior authorization requirements, and coding guidance for one-time administration of elivaldogene autotemcel (Skysona) for boys 4–17 years with early, active cerebral ALD for Baylor Scott & White Health Plan lines of business.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Esketamine (Spravato®) — Coverage CriteriaDefines medical necessity, prior authorization, and coverage criteria for esketamine (Spravato®) nasal spray for adults with treatment-resistant depression and related indications for Baylor Scott & White Health Plan members.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Gene Based Therapies for Duchenne Muscular DystrophyThis policy governs prior authorization and medical necessity criteria for gene-based and exon-skipping medications for Duchenne muscular dystrophy (DMD) for Baylor Scott & White Health Plan members, including casimersen, eteplirsen, golodirsen, viltolarsen, and delandistrogene moxeparvovec.All Baylor Scott & White Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Lecanemab-irmb (Leqembi) Coverage CriteriaDefines medical necessity and prior authorization requirements for lecanemab (Leqembi) for patients with MCI due to Alzheimer disease or mild AD dementia; applies to Baylor Scott & White Health Plan lines of business including Medicare and Medicaid as noted.All Baylor Scott & White Health Plan updates
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Tool Description
Search Baylor Scott & White Health Plan 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.
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