CareSource Coverage Criteria
Latest CareSource coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Mepsevii (vestronidase alfa-vjbk) Coverage CriteriaMedical prior authorization coverage for Mepsevii for CareSource Arkansas PASSE members with mucopolysaccharidosis type VII (MPS VII, Sly Syndrome), including authorization criteria, reauthorization, dosing, duration, and medical-necessity requirements.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Skin SubstitutesThis policy governs when CareSource considers skin substitutes medically necessary for chronic diabetic foot ulcers, venous insufficiency ulcers, burns, scar contractures, and pressure ulcers, as well as required clinical documentation and non-covered uses. It applies to providers treating Arkansas PASSE members.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Airway Clearance DevicesDefines medical necessity, coverage criteria, and exclusions for mechanical insufflation-exsufflation devices, high-frequency chest compression devices, and oscillation and lung expansion (OLE) devices for members, including clinical criteria and rental/purchase guidance.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Adzynma (ADAMTS13, recombinant-krhn) — Medical prior authorization and coverage criteria for congenital TTPDefines medical prior authorization and coverage criteria for Adzynma used as prophylactic or on‑demand enzyme replacement therapy in adult and pediatric patients with congenital thrombotic thrombocytopenic purpura (cTTP) for CareSource Arkansas PASSE.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01List of Covered Drugs (Drug List) — Coverage CriteriaDefines which drugs, OTC products, and non-drug items are covered under HAP CareSource MI Coordinated Health and explains rules, restrictions, and member/provider actions for obtaining covered drugs.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Mechanical Stretching Devices (Dynamic Splinting) — DME Coverage Criteria (AR PASSE)Policy governing coverage and clinical criteria for mechanical stretching devices (dynamic splinting systems) as durable medical equipment for members in the Arkansas PASSE program; defines when devices are medically necessary, non-covered, and documentation requirements.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Metabolic and Bariatric SurgeryDefines coverage criteria, documentation requirements, contraindications, and referral guidance for metabolic and bariatric surgery for CareSource members under the Arkansas PASSE policy.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Revisional Metabolic and Bariatric Surgery (Coverage Criteria)Defines medical necessity and coverage criteria for revision bariatric procedures for CareSource Arkansas PASSE members, including indications, exclusions, required documentation, and prior authorization requirements.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Sacroiliac Joint FusionDefines medical necessity, coverage criteria, exclusions, and related requirements for open and percutaneous (minimally invasive) sacroiliac joint (SIJ) fusion for CareSource Arkansas PASSE members.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Adaptive Seating for Special Needs - AR PASSEDefines medical necessity, coverage criteria, exclusions, and documentation requirements for adaptive seating systems and accessories for CareSource Arkansas PASSE members.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Breast Reduction Surgery (Reduction Mammoplasty) and Gynecomastia Surgery - Arkansas PASSEDefines medical necessity, coverage criteria, exclusions, and evaluation tools for breast reduction and gynecomastia surgery for CareSource members in Arkansas (AR PASSE); affects providers seeking authorization and payers adjudicating claims.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Implantable Pain Pump — Arkansas PASSEMedical necessity and coverage criteria for implantation, trialing, revision, removal, and single-shot intrathecal injections of implantable pain pumps for malignant and non-malignant severe chronic intractable pain for CareSource Arkansas PASSE members.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Radiofrequency and Microwave Ablation of TumorsThis policy governs coverage and medical necessity criteria for radiofrequency ablation (RFA) and microwave ablation (MWA) of tumors for CareSource members in Arkansas PASSE, specifying indications, size limits, and conditions affecting coverage.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Standing Frames – Non‑powered standing frames (Arkansas)Coverage and medical necessity criteria for non-powered standing frames (standers) for Arkansas members, including documentation, evaluation, replacement, and exclusions; applies to CareSource members in Arkansas (NC not listed).All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01CareSource Dual Advantage Formulary (Drug List) — Coverage CriteriaDescribes the prescription drugs covered by the CareSource Dual Advantage (HMO D-SNP) plan, how to use the formulary, and coverage controls (prior authorization, quantity limits, step therapy) for members and prescribing providers.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Evkeeza (evinacumab-dgnb) — Coverage Criteria for Homozygous Familial Hypercholesterolemia (HoFH)This policy governs prior-authorization medical benefit coverage of Evkeeza (evinacumab-dgnb) for members with homozygous familial hypercholesterolemia (HoFH) in Arkansas PASSE. It describes initial and reauthorization clinical criteria, required documentation, dosing, and coverage stance.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Experimental or Investigational Items or ServicesDefines CareSource's review and coverage stance for items or services considered experimental, investigational, or not medically necessary for Arkansas PASSE members; applies to coverage determinations and review processes for requested treatments.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Implantable Spinal Cord Stimulator (SCS) — Arkansas PASSEMedical necessity, contraindications, exclusions, and coverage criteria for trial and permanent implantation of implantable spinal cord stimulators for chronic pain and chronic stable angina for CareSource Arkansas PASSE members.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Palsonify (paltusotine) — Coverage Criteria (Arkansas PASSE)Defines prior authorization requirements and coverage criteria for Palsonify (paltusotine) for adult members with acromegaly under the pharmacy benefit for CareSource Arkansas PASSE.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Papzimeos (imadenovec-drba) — Coverage and Prior Authorization CriteriaDefines prior authorization, coverage criteria, and limits for Papzimeos (imadenovec-drba) as a medical benefit for adults with recurrent respiratory papillomatosis (RRP) in the payer's Arkansas PASSE program.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Skysona (elivaldogene autotemcel) — Prior authorization and coverage criteriaDefines prior authorization and medical necessity criteria for Skysona (elivaldogene autotemcel) as a one-time gene therapy for boys 4–17 years with early, active cerebral adrenoleukodystrophy (CALD); applies to the payer's pharmacy/medical benefit in Arkansas PASSE and affects prescribers and prior authorization reviewers.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Trigger Point InjectionsDefines medical necessity criteria, documentation requirements, limits, and payment rules for trigger point injections (TPIs) for back pain, neck pain, or myofascial pain syndrome for CareSource Arkansas PASSE.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Airway Clearance DevicesPolicy governing medical necessity and coverage criteria for airway clearance devices (mechanical insufflation-exsufflation and high-frequency chest compression devices) for members covered by CareSource; specifies clinical indications, contraindications, and documentation requirements.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Airway Clearance Devices (Mechanical Insufflation-Exsufflation E0482; High-Frequency Chest Compression E0483)Defines medical necessity and coverage criteria for mechanical insufflation-exsufflation (E0482) and high-frequency chest compression/HFCWO devices (E0483) for Arkansas PASSE members; affects ordering providers, durable medical equipment suppliers, and CareSource coverage determinations.All CareSource updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Epidural Steroid InjectionsDefines medical necessity criteria, limitations, exclusions, and procedural billing components for epidural steroid injections (translaminar/interlaminar, transforaminal, caudal) for chronic back pain for Arkansas PASSE members under CareSource.All CareSource updates
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Tool Description
Search CareSource 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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