Capital Bluecross Coverage Criteria
Latest Capital Bluecross coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Balloon Dilation of the Eustachian Tube (BDET)Clinical coverage policy for balloon dilation of the eustachian tube (BDET) for treatment of chronic obstructive eustachian tube dysfunction (ETD), including adult and pediatric guidance, diagnostic and contraindication requirements, and when the procedure is investigational.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Closure Devices for Patent Foramen Ovale (PFO) and Atrial Septal Defects (ASD)This policy governs when percutaneous transcatheter closure devices for PFO and ASD are considered medically necessary or investigational for Capital Bluecross members; it applies to use of FDA‑approved devices and describes clinical indications and limits.All Capital Bluecross updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Durable Medical Equipment and SuppliesDefines Capital Bluecross coverage rules for durable medical equipment and related supplies, including definitions, item-level medical necessity criteria, rental/purchase and replacement rules, examples of covered and not-covered items, and coding references affecting providers and members.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Esophagogastroduodenoscopy (EGD)Defines when diagnostic, therapeutic, and surveillance/periodic EGD is medically necessary, investigational, or not recommended; applies to products administered by Capital Bluecross with benefit variations noted.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Genetic testing for Lynch syndrome and other inherited colon cancer syndromesDefines medical necessity and investigational indications for germline and select somatic genetic tests related to Lynch syndrome, familial adenomatous polyposis (FAP), MUTYH-associated polyposis (MAP), and other inherited colon cancer syndromes for Capital Bluecross members and ordering clinicians.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Genetic testing for inherited thrombophiliaPolicy governs medical necessity and coverage criteria for genetic and protein testing for inherited thrombophilias (e.g., Factor V Leiden, prothrombin variant, protein C/S, antithrombin) for Capital Bluecross members.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Implantable Bone-Conduction and Bone-Anchored Hearing Prosthetic DevicesMedical necessity and coverage criteria for implantable bone-conduction (bone-anchored) hearing prosthetic devices for members aged 5 years and older, including device indications, audiologic thresholds, and investigational uses.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Recombinant and Autologous Platelet-Derived Growth Factors as a Treatment of Wound Healing and Other Non‑Orthopedic ConditionsThis policy governs medical coverage for recombinant platelet-derived growth factor (becaplermin) and autologous platelet-rich plasma (PRP) when used to treat non-orthopedic wounds, specifying indications considered medically necessary versus investigational and candidate criteria for use.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Temporomandibular Disorder (TMD) — Coverage CriteriaClinical coverage policy for diagnostic, nonsurgical, and surgical management of temporomandibular disorder (TMD); specifies medically necessary versus investigational procedures and cross-references related policies.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Allogeneic hematopoietic cell transplantation for myelodysplastic syndromes and myeloproliferative neoplasmsDefines medical necessity criteria and policy stance for myeloablative and reduced-intensity conditioning allogeneic hematopoietic cell transplantation (allo-HCT) in individuals with myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). Applies to Capital BlueCross members in North Carolina.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Deep Brain StimulationMedical policy governing coverage and medical necessity criteria for deep brain stimulation (DBS) procedures for movement disorders and select neurologic/psychiatric indications for members of Capital BlueCross programs.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid MyolysisDefines medical necessity and investigational status for laparoscopic and transcervical radiofrequency ablation (RFA) for symptomatic uterine fibroids in adults and states that other myolysis techniques (laser, bipolar needles, cryomyolysis, MRI-guided laser) are investigational. Applies to Capital BlueCross-administered products with benefit variations.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Treatment of Varicose Veins - Venous InsufficiencyDefines medical necessity criteria, investigational or cosmetic determinations, and coding guidance for surgical, endovenous, sclerotherapy, mechanochemical, cyanoacrylate, cryoablation, and phlebectomy treatments of varicose veins and venous insufficiency for Capital Blue Cross products (particular product variations noted). This is part 1 of 2 and includes clinical criteria, policy guidelines, background, evidence summary, definitions, regulatory status, and partial coding lists.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01External Infusion Pumps for Insulin Delivery and Automated Insulin Delivery SystemsGoverns medical necessity and coverage criteria for external insulin infusion pumps and FDA-cleared automated insulin delivery (AID) systems for individuals with diabetes, including indications, replacement rules, device classifications, and documentation required for prior authorization.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Hematopoietic Cell Transplantation for Chronic Myeloid LeukemiaDefines medical necessity and coverage stance for allogeneic and autologous hematopoietic cell transplantation (HCT) in individuals with chronic myeloid leukemia (CML), including myeloablative and reduced-intensity conditioning; intended for providers and coverage decision-makers.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Hematopoietic Cell Transplantation for Non-Hodgkin LymphomasMedical necessity and investigational coverage criteria for autologous and allogeneic hematopoietic cell transplantation (HCT) across specified non-Hodgkin lymphoma (NHL) subtypes and clinical scenarios, for Capital BlueCross products covered by this policy.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Radiofrequency Ablation of Miscellaneous Solid Tumors (excluding liver)This policy governs medical necessity and coverage criteria for radiofrequency ablation (RFA) of non-liver solid tumors (e.g., bone, kidney, lung, breast, and other miscellaneous tumors) and applies to Capital BlueCross-administered products with noted product variations.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Diagnosis of VaginitisClinical coverage criteria for laboratory and point-of-care testing used to diagnose causes of vaginitis (BV, VVC, trichomoniasis and related testing) for Capital Bluecross members.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Gender Affirming SurgeryDefines medical necessity criteria, covered procedures, coding guidance, documentation/referral letter requirements, detransition criteria, and product variations for Capital Blue Cross members for gender-affirming surgical interventions.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Genetic Testing for Mitochondrial DisordersDefines medical necessity, testing strategies, and guidance for genetic testing to establish a diagnosis of mitochondrial disorders and for targeted familial variant testing in at-risk relatives. Applies to providers and members covered under Capital Bluecross products where this policy is in effect.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Upper Limb ProsthesesThis policy governs medical necessity and coverage criteria for upper limb prosthetic devices and related components for members with upper limb amputation or absence, including preparatory, passive, body-powered, and myoelectric prostheses. It applies to Capital Bluecross-administered programs unless noted otherwise.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-06Adjustable Cranial Orthoses for Positional Plagiocephaly and CraniosynostosesThis policy governs when adjustable cranial orthoses (helmets/bands) are considered medically necessary or investigational for infants with positional plagiocephaly, brachycephaly, or craniosynostosis, and applies to Capital BlueCross-administered benefit programs unless product variations apply.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or BoneThis policy defines when cryosurgical ablation (cryoablation) is considered medically necessary or investigational for adults with tumors of the kidney, lung, breast, pancreas, or bone for Capital Blue Cross products.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Liver transplant and combined liver-kidney transplantThis policy governs medical necessity and selection criteria for cadaveric and living-donor liver transplantation, including combined liver-kidney transplant, and applies to Capital BlueCross-covered individuals undergoing evaluation or listing for transplant.All Capital Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Polysomnography (PSG) for Non‑Respiratory Sleep DisordersThis policy governs when attended facility-based polysomnography (PSG) and associated multiple sleep latency testing (MSLT) are considered medically necessary for evaluation of non-respiratory sleep disorders (hypersomnias, parasomnias, and sleep-related movement disorders) for members of Capital Bluecross products to which the policy applies.All Capital Bluecross updates
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Search Capital Bluecross 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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