Bcbsvermont Coverage Criteria
Latest Bcbsvermont coverage criteria updates19
- Coverage CriteriaClinical/Medical PolicyEff. 2027-01-01Adjustable Cranial Orthoses for Positional Plagiocephaly and CraniosynostosesThis policy governs medical necessity, prior approval, coding, and coverage criteria for adjustable cranial orthoses used in pediatric individuals with postsurgical craniosynostosis or persistent positional plagiocephaly or brachycephaly without synostosis. Benefits remain subject to the member’s applicable contract or benefit plan.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Cognitive Rehabilitation Corporate Medical PolicyThis policy governs coverage of cognitive rehabilitation as a distinct component of rehabilitation for members with moderate to severe traumatic brain injury or specified acquired brain injuries. It establishes medical-necessity criteria, investigational applications, eligible providers, and applicable diagnosis coding guidance.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Electrical Bone Growth Stimulation of the Appendicular SkeletonThis policy governs coverage and medical-necessity determinations for noninvasive, implantable, and semi-invasive electrical bone growth stimulation for appendicular-skeleton conditions for Blue Cross Blue Shield of Vermont members, subject to the applicable benefit plan.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Physical Therapy/Medicine Corporate Medical PolicyCoverage, medical necessity, exclusions, and investigational status for physical therapy and physical medicine services for individuals of all ages with musculoskeletal, neuromuscular, or integumentary impairments.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Speech Language Pathology/Therapy Services Corporate Medical PolicyCoverage and medical necessity for evaluation and treatment of swallowing, speech-language, and cognitive-communication disorders, including certain autism spectrum disorder services, subject to applicable benefit limits and exclusions.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Dermatologic Applications of Photodynamic Therapy Corporate Medical PolicyThis policy governs coverage, medical necessity, investigational status, benefit exclusions, prior approval, and coding for photodynamic therapy used for dermatologic conditions. It applies to qualified healthcare professionals and members whose benefits are administered under applicable Blue Cross Blue Shield of Vermont contracts or benefit plans.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Diagnosis and Treatment of Sacroiliac Joint PainThis policy governs coverage and medical-necessity criteria for diagnostic and therapeutic sacroiliac joint injections, SI joint fixation or fusion, nerve blocks, and radiofrequency procedures, subject to the member’s contract or benefit plan.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Laser Interstitial Thermal Therapy for Neurological ConditionsThis policy governs coverage of laser interstitial thermal therapy (LITT) for refractory epilepsy, relapsed brain metastases, radiation necrosis, and glioblastoma, including criteria for medically necessary versus investigational use.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Light Therapy for Dermatologic ConditionsMedical necessity and coverage criteria for PUVA, UVB phototherapy, targeted phototherapy, and home ultraviolet light systems for dermatologic conditions.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Nutritional Counseling Corporate Medical PolicyThis policy governs when nutritional counseling and medical nutrition therapy may be medically necessary, which providers may furnish the services, and the applicable procedure codes and prior-approval requirements. It applies to BCBS Vermont members subject to their applicable contract and benefit terms.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Private Inpatient Hospital Rooms Corporate Medical PolicyThis policy governs when a private hospital room is medically necessary for an inpatient member and when private-room or deluxe-accommodation charges are not medically necessary, subject to the member's contract and benefit plan.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Allergy Testing, Including Selected Blood, Serum and Cellular Testing and Toxicity Testing Corporate Medical PolicyThis policy governs coverage of specified allergy testing and selected blood, serum, cellular, and toxicity-related tests. It identifies testing that may be medically necessary, not medically necessary, or investigational for members when the stated clinical criteria are met.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Home Infusion Therapy Corporate Medical PolicyThis policy governs coverage and medical necessity for home infusion therapy delivered through intravenous solutions or injectable medications for Blue Cross Blue Shield of Vermont members, subject to the member’s contract and benefit plan.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic ConditionsThis policy governs medical necessity, prior approval, documentation, and coding requirements for proton or helium-ion radiotherapy used to treat benign or malignant tumors and hematologic malignancies. Coverage varies by tumor type, patient age, clinical circumstances, and whether the application is considered investigational.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion ProceduresCoverage and prior approval for invasive and noninvasive electrical bone growth stimulation used with spinal fusion surgery or to treat failed spinal fusion, subject to the member’s applicable benefit plan.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disorders Corporate Medical PolicyThis policy governs coverage and prior approval for the IB-STIM percutaneous electrical nerve field stimulation device for children and adolescents with Rome IV-defined functional gastrointestinal disorders. It also addresses investigational uses, coding, durable medical equipment replacement, and benefit administration for Blue Cross Blue Shield of Vermont members.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Tumor Treatment Fields for CNS Cancers Corporate Medical PolicyThis policy governs medical necessity and coverage of tumor treating fields therapy for selected CNS tumors, including glioblastoma and specified anaplastic gliomas, subject to member benefits and contract terms.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Monitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy, Bronchoscopy, or Interventional Pain Procedures in Outpatient SettingsThis policy governs when monitored anesthesia care (MAC) may be medically necessary for outpatient gastrointestinal endoscopy, bronchoscopy, and interventional pain procedures. It applies to providers documenting patient-specific risk factors, procedure characteristics, and applicable anesthesia services.All bcbsvermont updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-04-01Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders Corporate Medical PolicyThis policy governs coverage and medical necessity for wireless capsule endoscopy, patency capsule use, and magnetic capsule endoscopy for gastrointestinal conditions. It applies to providers seeking reimbursement from Blue Cross Blue Shield of Vermont, subject to the member’s contract and required prior approval.All bcbsvermont updates
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Search Bcbsvermont 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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