Centene Coverage Criteria
Latest Centene coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Air AmbulanceDefines medical necessity criteria and coding guidance for fixed-wing and rotary-wing air ambulance transports for members/enrollees of Centene-affiliated health plans; applies to providers requesting or billing for air medical transport.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Allogeneic Hematopoietic Progenitor Cell TherapyMedical necessity criteria for non‑Medicare Centene-affiliated health plans for allogeneic hematopoietic progenitor cell therapies including Omisirge (omidubicel) and RegeneCyte (HPC Cord Blood), and guidance for patient selection and coding.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Allogeneic Hematopoietic Progenitor Cell TherapyMedical necessity criteria for use of Omisirge (omidubicel) and RegeneCyte (HPC Cord Blood) for non‑Medicare Centene-affiliated health plans; who may qualify and under what conditions.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Clinical Policy: Air AmbulanceMedical necessity criteria and coding guidance for fixed‑wing and rotary‑wing air ambulance transport for members/enrollees of Centene-affiliated health plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Disc Decompression ProceduresDefines medical necessity criteria for open discectomy and microdiscectomy for lumbar disc herniation and states Centene's position on various minimally invasive disc decompression procedures; applies to Centene-affiliated health plans and providers submitting requests for these procedures.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Drugs of Abuse: Definitive TestingOutpatient definitive/confirmatory (quantitative) drug testing for drugs of abuse in urine and other specimens, governing medical necessity criteria, coding implications, and exclusions for Centene-affiliated health plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Immobilized Lipase Cartridges (RELiZORB)Medical necessity criteria and coverage guidance for use of RELiZORB immobilized lipase cartridges with enteral feeding for members of Centene-affiliated health plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Liposuction for LipedemaThis policy governs medical necessity criteria and coverage guidance for liposuction as a treatment for lipedema for members of Centene-affiliated health plans. It affects providers requesting authorization and payers making coverage decisions.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Multiple Sleep Latency Testing (MSLT) Coverage CriteriaDefines medical necessity criteria and coding guidance for Multiple Sleep Latency Testing (MSLT) for members/enrollees age two years and older, and requirements for repeat testing. Applies to health plans affiliated with Centene Corporation.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Therapeutic Utilization of Inhaled Nitric OxideDefines medical necessity, continuation, and noncoverage criteria for initiation and continued use of inhaled nitric oxide in neonates, infants, children, and select adult indications (including COVID-19 severe ARDS) for Centene-affiliated health plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Clinical Policy: Pancreas TransplantationClinical policy governing medical necessity and coverage criteria for pancreas transplantation for Centene members; affects providers submitting requests for pancreas transplant services and associated CPT coding.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Pancreas TransplantationDefines medical necessity criteria, contraindications, and coding guidance for pancreas transplantation (PTA, SPK, PAK), autologous islet autotransplantation, and retransplantation for Centene-affiliated health plans; affects providers requesting coverage for these procedures.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Tandem TransplantDefines medical necessity criteria for planned sequential (tandem) autologous hematopoietic cell transplants — including tandem autologous → reduced-intensity allogeneic sequences — for specified diagnoses and patient eligibility; applies to Centene-affiliated health plans and providers requesting authorization.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Tandem TransplantMedical necessity criteria for planned tandem (sequential/double) high-dose therapy with hematopoietic cell transplant (HCT) within six months of the first course, for members/enrollees of Centene-affiliated health plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Assisted Reproductive TechnologyDefines medical necessity criteria, covered and not medically necessary assisted reproductive technologies (ART) for members whose benefits include infertility services; applies to both female and male reproductive system services under Centene-affiliated health plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Clinical Policy: Heart-Lung TransplantMedical necessity criteria and coverage considerations for heart-lung transplantation for Centene members, including indications, contraindications, and coding implications. Applies to providers requesting authorization for combined heart and lung transplant services.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Clinical Policy: Nerve Blocks and Neurolysis for Pain ManagementMedical necessity and coverage criteria for various peripheral and sympathetic nerve blocks, celiac plexus interventions, intercostal and peripheral/ganglion blocks, and related procedures for non-Medicare Centene-affiliated health plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Deep Transcranial Magnetic Stimulation (dTMS) for Obsessive-Compulsive DisorderMedical necessity and coverage criteria for initial, maintenance, and retreatment use of deep transcranial magnetic stimulation (dTMS) for members with obsessive-compulsive disorder (OCD) under Centene-affiliated plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive DisorderMedical necessity and coverage criteria for using deep transcranial magnetic stimulation to treat adults with obsessive-compulsive disorder for Centene-affiliated health plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Donor Lymphocyte InfusionMedical necessity and coverage criteria for donor lymphocyte infusion following allogeneic hematopoietic stem cell transplantation for relapsed or high-risk hematologic malignancies, applicable to non-Medicare Centene health plans.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Donor Lymphocyte InfusionMedical necessity criteria and coverage guidance for donor lymphocyte infusion (DLI) following allogeneic hematopoietic stem cell transplantation (HSCT) for non‑Medicare Centene-affiliated health plans; includes indications, contraindications, and coding implications.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Home VentilatorsMedical necessity criteria for coverage of noninvasive and invasive home ventilators for non‑Medicare health plans affiliated with Centene, including initial and continued use, backup devices, and indications such as restrictive thoracic disorders, COPD, and obesity hypoventilation syndrome.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Home VentilatorsMedical necessity criteria for initial and continued use of noninvasive and invasive home ventilators for non‑Medicare Centene-affiliated plans; who qualifies and documentation/prior authorization expectations.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Lung TransplantationDefines medical necessity criteria for lung transplantation for non-Medicare Centene-affiliated health plans (members/enrollees with chronic end-stage lung disease) including eligibility disease-specific thresholds, absolute contraindications, and references to Medicare-specific policy. Also lists relevant CPT/HCPCS codes for transplantation procedures and donor procurement.All Centene updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Lung Transplantation Medical Necessity CriteriaDefines medical necessity criteria and coding guidance for lung transplantation requests for Centene members, based on ISHLT 2021 consensus guidance; affects clinicians and transplant program reviewers evaluating transplant eligibility.All Centene updates
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Tool Description
Search Centene 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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