CareFirst Coverage Criteria
Latest CareFirst coverage criteria updates15
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Neuropsychological TestingDefines medical necessity and investigational uses of neuropsychological testing for CareFirst members, adopting MCG Care Guidelines for clinical criteria and applicability; affects providers requesting or performing neuropsychological assessments for diagnosis, pre/postoperative evaluation, or rehabilitation planning.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Oral-Facial PathologyClinical criteria for medically necessary diagnosis and surgical/non-surgical treatment of oral-facial pathology (including orthognathic surgery, tumor excision, congenital anomalies such as cleft lip/palate, salivary gland procedures, and related dental care when medically necessary) for CareFirst members.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Respiratory Syncytial Virus (RSV) Vaccines for AdultsDefines medical necessity and coverage criteria for RSV vaccines (Abrysvo, Arexvy, mRESVIA) in adults and for Abrysvo in pregnancy, for CareFirst-managed benefits.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Therapeutic ApheresisDefines medical necessity indications and experimental/investigational exclusions for therapeutic apheresis procedures; CareFirst adopts MCG Care Guidelines® for clinical criteria and requires checking member contract and prior authorization when applicable.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Bone Density StudiesGoverns coverage and medical necessity criteria for one non-invasive bone density measurement (SPA, DPA, QCT, or DEXA) for CareFirst members, including indications for treatment decision-making, monitoring secondary osteoporosis, and annual monitoring during active osteoporosis therapy.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Prostatic Urethral Lift (UroLift®) for Benign Prostatic HypertrophyDefines CareFirst coverage stance for the prostatic urethral lift (UroLift®) as a surgical treatment alternative for benign prostatic hypertrophy (BPH) when surgical intervention is indicated; applies to providers and members under CareFirst plans.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-017.01.116 RETIRED Transcatheter Pulmonary Valve ImplantationDefines medical necessity and coverage criteria for transcatheter pulmonary valve implantation (TPVI) for members of CareFirst, aligning with MCG Cardiac Valve Replacement or Repair guidelines; affects providers submitting for TPVI and related prior authorization.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Minimally Invasive Sacroiliac Joint FusionClinical coverage criteria and requirements for minimally invasive sacroiliac joint fusion/stabilization (primarily using titanium triangular implants) for members covered by CareFirst; intended for providers requesting authorization or determining medical necessity.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Extracorporeal Shock Wave Lithotripsy (ESWL) for gallbladder and pancreatic stonesDefines medical necessity criteria and coverage stance for ESWL to treat gallstones, common bile duct stones, and pancreatic duct stones for CareFirst members; applies to providers submitting prior authorization and coverage requests.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-01-01Dialectical Behavior TherapyGoverns coverage of outpatient Dialectical Behavior Therapy for members when clinical criteria are met; applies to CareFirst members per contract provisions.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-10-06DecisionDx-UM gene expression profile for uveal melanoma — Coverage CriteriaGoverns coverage of the DecisionDx-UM 15-gene expression profile for patients with uveal (uveal tract) melanoma; affects ordering providers, laboratories, and CareFirst members.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 1998-04-01Air Fluidized BedsGoverns medical necessity and coverage criteria for air fluidized beds (HCPCS E0194) for treatment of pressure ulcers and extensive burns in non-ambulatory, bedridden patients; affects providers and prior-authorization processes for CareFirst members.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyComprehensive dental restorative services (CDT D2000-D2999)Guidance for coding, coverage expectations, frequency limits, and documentation requirements for restorative dental CDT codes D2000-D2999 for CareFirst members and participating programs.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyFracture / Traction Frames and Associated EquipmentCoverage and medical necessity criteria for fracture and traction frames and associated equipment (DME) used to immobilize and align injured extremities or pelvis for CareFirst members; excludes cervical traction which is covered under a separate DME policy.All CareFirst updates
- Coverage CriteriaClinical/Medical PolicyRhinomanometry and Acoustic Rhinometry Coverage CriteriaThis policy addresses the use of rhinomanometry and acoustic rhinometry to evaluate nasal airway patency and related clinical applications (e.g., allergy testing, obstructive sleep apnea evaluation, preoperative assessment) for CareFirst members.All CareFirst updates
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Search CareFirst 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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