Care_continuum Coverage Criteria
Latest Care_continuum coverage criteria updates19
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-18Reduction Mammoplasty (Breast Reduction) — Coverage CriteriaClinical guidance for Utilization Management Coordinators and reviewers on medical necessity determinations for reduction mammoplasty (breast reduction) surgeries for Network Health Plan members.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-21Drug, Drug Metabolite and Alcohol Testing Frequency PolicyDefines medical necessity criteria, frequency limits, and non-covered indications for drug, metabolite and alcohol testing in behavioral health and chronic opioid therapy settings for Network Health members; applies to utilization management decisions by the payer's reviewers and treating practitioners.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Continuous Glucose MonitorThis policy governs prior authorization requirements and coverage criteria for prescription continuous glucose monitors (Dexcom and FreeStyle Libre) for Medicare and Commercial members of Care Continuum.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-18Acupuncture — Coverage Criteria (CMS NCD 30.3.3 for chronic low back pain)Guidance for utilization management determinations of medical necessity for acupuncture services across lines of business; informs reviewers on coverage criteria and references including CMS NCDs (not state-limited).All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-02-17Pneumatic Compression DevicesDefines medical necessity, coverage criteria, limitations, and billing codes for pneumatic compression devices for Network Health Plan members, including Medicare Advantage where CMS NCD/LCD apply.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-03-01Nerve Blocks and Ablation Therapy for the Treatment of PainDefines medical necessity criteria and exclusions for peripheral nerve blocks and ablation therapies for treatment of acute and chronic pain for Network Health Plan members, including guidance for Medicare Advantage when CMS NCD/LCD are absent.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-11Endobronchial Valves for the Treatment of Severe EmphysemaDefines medical necessity, coverage, limitations, and coding guidance for use of the Zephyr® endobronchial valve system to treat severe emphysema for Network Health lines of business, including Medicare Advantage members.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-06-20Specialized Manual Wheelchairs — Coverage CriteriaDefines medical necessity, coverage, limitations, and coding for specialized manual wheelchairs for Network Health commercial lines; Medicare Advantage follows applicable CMS NCDs/LCDs. Applies to providers and utilization management decisions for the payer's membership.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-06-19Home Phototherapy Units (UVB) — Coverage CriteriaDefines medical necessity criteria and coverage stance for home ultraviolet B (UVB) phototherapy devices for treatment of skin conditions for Network Health members, including application to Medicare Advantage where CMS determinations are absent.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-05-01Orthognathic SurgeryDefines medical necessity criteria, coding, coverage limitations, and documentation guidance for orthognathic (jaw) surgery for Network Health members; applies to clinicians and utilization management reviewers determining coverage eligibility.All care_continuum updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2017-01-01Outpatient Observation ServicesThis policy governs reimbursement and billing rules for outpatient hospital observation services when Medicare coverage criteria are met, affecting providers submitting observation service claims to Care Continuum (Network Health).All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2000-07-27Reduction Mammoplasty MedicalDefines medical necessity criteria, documentation requirements, and exclusions for coverage of reduction mammoplasty for Network Health/Network Health Insurance Corporation/Network Health Administrative Services members, including application to Medicare Advantage when CMS determinations are absent.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyBenign Skin, Subcutaneous, and Oral LesionsThis policy governs when removal or treatment of benign cutaneous, subcutaneous, and oral lesions is considered medically necessary and covered for members of Network Health Plan/Network Health Insurance Corporation/Network Health Administrative Services, including Medicare Advantage when CMS NCDs/LCDs apply.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyClinical Criteria for Utilization Decisions Desk ProcedureDefines how Care Continuum (NHP/NHIC/NHAS/NH TPA) applies nationally recognized and regionally developed medical policies and criteria for utilization management reviews affecting reviewers, delegated UM entities, providers, and members for commercial, marketplace, and Medicare Advantage requests.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyClinical Criteria for Utilization Decisions Desk ProcedureDescribes how the Utilization Management department applies nationally recognized and regionally developed utilization criteria and medical policies to prior authorization and coverage determinations for members, including Medicare Advantage, and how UM staff and medical leadership review and apply those criteria.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyPublished Review CriteriaThis policy governs Network Health/Network Health Insurance/Network Health Administrative Services (and NH TPA) Utilization Management use of nationally published clinical criteria to make medical necessity decisions for covered members.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicyReal-Time Mobile Cardiac Outpatient TelemetryClinical coverage policy governing use and medical necessity criteria for real-time mobile cardiac telemetry (MCT/MCOT) for Network Health Plan members, including Medicare Advantage where CMS NCDs/LCDs apply.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicySkin Substitutes and Other Advanced Wound Healing ProductsClinical coverage and medical necessity criteria for use of biologic and bioengineered skin substitutes and related advanced wound healing products for Network Health members, including indications, limits on applications, and documentation expectations.All care_continuum updates
- Coverage CriteriaClinical/Medical PolicySurgical Treatment for Temporomandibular DisordersPolicy governing medical necessity review and coverage guidance for surgical interventions for temporomandibular disorders (TMD) for Network Health members; clinical criteria and coding guidance to be applied by utilization management reviewers and providers.All care_continuum updates
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Tool Description
Search Care_continuum 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
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