Colorado Rocky Mountain Health Plans Coverage Criteria
- Colorado Rocky Mountain Health Plans prior authorization
- All Colorado Rocky Mountain Health Plans policy updates
Latest Colorado Rocky Mountain Health Plans coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Adult Neck Imaging Guidelines (Ohio)Coverage and medical necessity criteria for radiology imaging of the adult neck for UnitedHealthcare Community Plan members in Ohio. Applies to providers requesting imaging services in the state of Ohio and explains guideline development and application.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Adult Spine Imaging Guidelines (Ohio) — Radiology Imaging Coverage Determination GuidelineCoverage and medical necessity criteria for advanced and conventional spine imaging modalities in adults, applicable only to UnitedHealthcare Community Plan members in the state of Ohio.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Pediatric Neck Imaging Guidelines (Ohio)Coverage and medical necessity criteria for radiology imaging of the pediatric neck for UnitedHealthcare Community Plan members in Ohio.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Brow Ptosis and Eyelid RepairCoverage criteria for brow ptosis and eyelid reconstructive procedures (blepharoplasty, ptosis repair, canthoplasty/canthopexy, lid retraction, lagophthalmos repair, floppy eyelid syndrome) for Commercial and Individual Exchange members; InterQual criteria apply to persons 18 years or older.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Camzyos (mavacamten) prior authorization / medical necessityPolicy governing prior authorization and medical necessity criteria for Camzyos (mavacamten) for adults with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy; applies to Colorado Rocky Mountain Health Plans pharmacy benefit and prescribers seeking coverage.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Carrier Testing Panels for Genetic DiseasesDefines coverage and medical necessity criteria for reproductive carrier screening panels and pan-ethnic carrier screening, and guidance for providers ordering these tests under Colorado Rocky Mountain Health Plans.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Clinical Pharmacy Prior Authorization and Coverage Criteria — Afinitor (everolimus)This document sets Colorado Rocky Mountain Health Plans' clinical pharmacy prior authorization and coverage criteria for Afinitor (everolimus), describing indications, initial and reauthorization requirements, and pediatric processing rules for members.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Continuous Glucose Monitoring and Insulin Delivery for Managing DiabetesMedical policy governing coverage criteria for continuous glucose monitoring (CGM) systems and external insulin delivery (insulin pumps) for UnitedHealthcare Commercial and Individual Exchange benefit plans.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Cosentyx (secukinumab) prior authorization — coverage criteriaDefines prior authorization, initial approval, and reauthorization criteria for Cosentyx (secukinumab) prefilled syringe or Sensoready pen for multiple indications under Colorado Rocky Mountain Health Plans.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Daraprim (pyrimethamine) — Prior Authorization and Medical NecessityDefines prior authorization and medical necessity criteria for outpatient coverage of Daraprim (pyrimethamine) for Colorado Rocky Mountain Health Plans members, including indications, documentation, and duration of authorization.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Encelto (Revakinagene Taroretcel-Lwey) implant — coverage criteriaDefines clinical coverage and authorization requirements for Encelto implant therapy for adults with idiopathic macular telangiectasia type 2 under UnitedHealthcare Commercial and Individual Exchange benefit plans.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Epidural Steroid Injections for Spinal Pain (for Ohio Only)This policy governs medical necessity, coverage criteria, and coding for epidural steroid injections (ESIs) for radicular spinal pain and applies only to Ohio; it informs providers and prior authorization reviewers about requirements for coverage under Colorado Rocky Mountain Health Plans.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Fabhalta (iptacopan) prior authorization — Coverage CriteriaDefines prior authorization and reauthorization criteria for Fabhalta (iptacopan) for adults with PNH, primary IgA nephropathy (IgAN) at risk of rapid progression, and complement 3 glomerulopathy (C3G); applies to Colorado Rocky Mountain Health Plans pharmacy benefits.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Fabhalta (iptacopan) — Prior authorization and medical necessity criteriaPrior authorization and medical necessity criteria for Fabhalta (iptacopan) for adults with PNH, primary IgA nephropathy (IgAN) at risk of rapid progression, and complement 3 glomerulopathy (C3G); applies to Colorado Rocky Mountain Health Plans pharmacy benefit.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Fotivda (tivozanib) — Prior Authorization and Coverage CriteriaPrior authorization and coverage criteria for Fotivda (tivozanib) for treatment of relapsed or refractory advanced renal cell carcinoma; affects prescribers and members covered by Colorado Rocky Mountain Health Plans and UnitedHealthcare Pharmacy prior authorization programs.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Genetic Testing for Hereditary CancerDefines medical necessity and coverage criteria for germline genetic testing for hereditary cancer syndromes, and lists applicable procedure codes; applies to Colorado Rocky Mountain Health Plans membership except where state-specific policies override.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech)This policy governs medical necessity, documentation, and coverage criteria for habilitation, rehabilitation, and maintenance outpatient occupational, physical, and speech therapy services for Colorado Rocky Mountain Health Plans members (state-specific exceptions listed). It applies to providers requesting evaluation, ongoing therapy, re-evaluations, group therapy, and feeding/swallowing services.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Hematopoietic Stem Cell TransplantationClinical guideline governing medical necessity and coverage criteria for autologous and allogeneic hematopoietic stem cell transplantation for Ohio members; describes indications, contraindications, evaluation and center requirements referenced to Ohio Administrative Code and InterQual® criteria.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Korsuva (difelikefalin) — Medical Benefit Drug Coverage Criteria (Ohio)Medical benefit drug coverage criteria for Korsuva (difelikefalin) for adults with moderate-to-severe CKD-associated pruritus receiving hemodialysis in Ohio.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Methyldopa — Prior Authorization / Medical NecessityDefines prior authorization and medical necessity criteria for coverage of methyldopa under Clinical Pharmacy Programs for Colorado Rocky Mountain Health Plans members.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Ohio Only)Ohio-specific policy governing coverage and medical necessity criteria for minimally invasive procedures to treat upper GI disorders (GERD, achalasia, gastroparesis) for Colorado Rocky Mountain Health Plans members in Ohio.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment DecisionsDefines coverage and medical necessity criteria for multigene panels, comprehensive genomic profiling (CGP), and clonality/MRD testing for hematologic malignancies under UnitedHealthcare Commercial and Individual Exchange plans.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment DecisionsDefines coverage rationale and criteria for molecular and genomic testing used for diagnosis, prognosis, and treatment decisions in solid tumor cancers for Colorado Rocky Mountain Health Plans members; applies to non-FDA-cleared/approved companion diagnostic tests. Affects ordering providers, laboratories, and claims reviewers.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Oxlumo (lumasiran) and Rivfloza (nedosiran) — Coverage Criteria (Ohio)Defines medical benefit drug coverage criteria for Oxlumo and Rivfloza for treatment of primary hyperoxaluria type 1 (PH1); applies to requests evaluated under Ohio jurisdiction per the policy.All Colorado Rocky Mountain Health Plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Panniculectomy Surgery (for Ohio Only)Defines coverage and medical necessity criteria for panniculectomy (Ohio only) including when it is reconstructive/medically necessary versus cosmetic/not medically necessary, and references InterQual criteria and documentation requirements.All Colorado Rocky Mountain Health Plans updates
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Tool Description
Search Colorado Rocky Mountain Health Plans 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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