Community Health Plan Washington Coverage Criteria
- Community Health Plan Washington prior authorization
- All Community Health Plan Washington policy updates
Latest Community Health Plan Washington coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Hematopoietic Agents – Sickle Cell Disease Cell and Gene TherapiesDefines medical necessity criteria, dosing/quantity limits, coding, and authorization rules for the two one-time gene therapies (Casgevy and Lyfgenia) for sickle cell disease with recurrent vaso-occlusive crises/events for Apple Health (Community Health Plan Washington). Also requires treatment centers to be CIBMTR-enrolled per CMS CMMI model.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-05-01Genetic Testing: Aortopathies and Connective Tissue Disorders — Coverage CriteriaDefines medical necessity criteria for genetic and multigene panel testing to diagnose or confirm hereditary aortopathies and connective tissue disorders for members of the health plan; applies to providers ordering genetic testing for these conditions.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-11-24Genetic testing for hereditary hearing loss (GJB2/GJB6 sequencing, deletion/duplication, and multigene panels)Defines medical necessity criteria for GJB2 and GJB6 sequencing/deletion-duplication analysis and multigene panel testing to diagnose hereditary (syndromic or nonsyndromic) hearing loss for members of the health plan.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-10-31Genetic and molecular testing for solid organ transplantation — Coverage criteriaCriteria and coding guidance for use of genetic and molecular laboratory tests (e.g., donor-derived cell-free DNA, gene expression panels, HLA typing) in the evaluation and management of solid organ transplant candidates and recipients.All Community Health Plan Washington updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2024-08-24Concert Genetic Testing: Toxicology and Pharmacogenetics (Version B)Defines medical necessity criteria, example tests, and coding implications for pharmacogenetic and toxicology-related genetic tests used to assess drug response, toxicity, and metabolizer status for members of Community Health Plan Washington (Centene-affiliated plans). Affects providers ordering or billing for pharmacogenetic and selected single-gene variant tests.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyAllogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β -ThalassemiaMedical necessity criteria and coverage guidance for AHCT in members with sickle cell anemia or homozygous β-thalassemia, intended for Medicare health plans affiliated with Centene (affects providers requesting transplant authorization).All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyAllogeneic Hematopoietic Progenitor Cell TherapyMedical necessity criteria for FDA‑approved allogeneic hematopoietic progenitor cell therapies (Omisirge/omidubicel and RegeneCyte/HPC cord blood) for Medicare health plans affiliated with Centene Corporation; governs coverage decisions for eligible members receiving related transplant procedures.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyAllogeneic Hematopoietic Progenitor Cell TherapyMedical necessity criteria for FDA-approved allogeneic hematopoietic progenitor cell therapies Omisirge (omidubicel) and RegeneCyte (HPC Cord Blood) for Medicare health plans affiliated with Centene Corporation; describes when these products are considered medically necessary.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyAllogeneic Hematopoietic Progenitor Cell TherapyMedical necessity criteria for FDA‑approved allogeneic hematopoietic progenitor cell therapies (Omisirge/omidubicel and RegeneCyte/HPC Cord Blood) for Medicare health plans affiliated with Centene Corporation; governs coverage decisions for patients meeting the listed clinical criteria.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyApplication of the Concert Genetics Clinical Policies for Medicare BeneficiariesGoverns how Concert Genetics molecular genetic test medical necessity criteria are applied for Medicare Advantage members of Centene-affiliated health plans when Medicare NCDs/LCDs do not fully establish coverage; affects providers ordering genetic tests for these members.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyCONCERT GENETIC TESTING: Prenatal and Preconception Carrier ScreeningDefines medical necessity criteria and coding for carrier genetic testing (expanded and basic panels and gene-specific tests) for individuals considering pregnancy or who are currently pregnant, and for reproductive partners when indicated.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyCONCERT Genetic Testing Oncology: Cancer Screening and SurveillanceThis policy governs the medical necessity and coverage criteria for genetic and biomarker tests used to screen for specific cancers (including colorectal, lung, and multi-cancer early detection) for insured members, addressing average- and increased-risk individuals.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyCONCERT Genetic Testing: Dermatologic ConditionsCriteria for when genetic and multigene panel testing for dermatologic conditions (e.g., CM-AVM, congenital ichthyosis, and other rare skin disorders) is considered medically necessary or investigational for members of Community Health Plan Washington.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Donor Lymphocyte InfusionDefines medical necessity criteria for donor lymphocyte infusion after allogeneic hematopoietic stem cell transplantation for Medicare health plans affiliated with Centene, including indications, contraindications, and coding implications.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Lung TransplantationDefines medical necessity criteria and coding guidance for lung transplantation for Medicare members/enrollees, based on ISHLT 2021 consensus, and describes candidate selection, contraindications, and disease-specific indications.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Lung TransplantationMedical necessity criteria and coding guidance for lung transplantation for Medicare-affiliated members/enrollees, based on ISHLT 2021 consensus guidance and payer-specific adaptations. Applies to evaluation and coverage decisions for lung transplant requests.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Pediatric Kidney TransplantMedical necessity criteria and coverage guidance for pediatric (age <18) kidney transplantation for Medicare health plans affiliated with Centene Corporation, including candidate selection and contraindications.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyConcert Genetic Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)Defines medical necessity and investigational indications for ctDNA (liquid biopsy) molecular profiling panels, focused lung panels, and specific variant analyses (EGFR, BRAF, KRAS, PIK3CA) for oncology care; applies to providers ordering these tests for members of the plan.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyConcert Genetic Oncology: Cytogenetic Testing (Tumor-specific FISH, IHC, PCR, targeted fusion panels)Defines medical necessity criteria and coding examples for cytogenetic and tumor protein testing (FISH, CISH, IHC, selected NGS fusion panels) for solid tumors and hematologic malignancies; applies to providers and members covered by the payer.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyConcert Genetic Testing HematologyDefines medical necessity criteria and coding implications for genetic tests used to diagnose or confirm non-cancerous hematologic disorders (e.g., thrombophilia, hemoglobinopathies, hemophilia, Fanconi anemia) for members of the payer plan.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyConcert Genetic Testing: Cardiac Disorders — Coverage CriteriaPolicy governing genetic and gene-expression testing related to cardiomyopathies, arrhythmias, congenital heart defects, cholesterol disorders, and post-heart-transplant rejection assessment for Community Health Plan Washington members and their providers.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyConcert Genetic Testing: Cardiovascular (Genetic testing for cardiovascular conditions)Defines medical necessity, coding, and usage guidance for genetic testing (multigene panels and targeted tests) for inherited and sporadic cardiovascular conditions for members of Community Health Plan Washington/Centene-affiliated health plans.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyConcert Genetic Testing: GastroenterologyDefines medical necessity criteria, coding implications, and related guidance for genetic and algorithmic laboratory tests used in non‑cancer gastroenterologic conditions (e.g., hereditary hemochromatosis, hereditary pancreatitis, inflammatory bowel disease, noninvasive liver disease). Applies to members of the payer's health plans.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyConcert Genetic Testing: Hematologic Conditions (Noncancerous) — Genetic & Molecular Testing Coverage CriteriaCriteria for when genetic and molecular tests for noncancerous hematologic disorders are considered medically necessary or investigational for members of the health plan; applies to providers ordering such tests through the Concert platform.All Community Health Plan Washington updates
- Coverage CriteriaClinical/Medical PolicyConcert Genetic Testing: Immunology and RheumatologyDefines medical necessity criteria and coding considerations for genetic and genomic tests used to evaluate autoimmune, immune deficiency, periodic fever syndromes, and rheumatoid arthritis in the immunology/rheumatology setting; applies to members of Community Health Plan Washington through Centene-affiliated plans.All Community Health Plan Washington updates
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Tool Description
Search Community Health Plan Washington 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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