Curative Coverage Criteria
Latest Curative coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyA003. Acute Heart Failure / Heart Failure ExacerbationThis policy governs medical necessity for acute inpatient admission, observation or outpatient management, level-of-care assignment, continued stay, and discharge readiness for adults with new-onset acute heart failure or acute decompensation of chronic heart failure, including heart-failure-related cardiogenic shock. It applies to Curative commercial PPO and EPO members in fully insured, level-funded, and self-funded plans.All curative updates
- Coverage CriteriaClinical/Medical PolicyA061. Hip Fracture — Acute Inpatient Management of Closed Proximal Femur FracturesGoverns acute inpatient admission, level of care, continued stay, and discharge readiness for Curative commercial members with closed proximal femur fractures treated surgically or, in selected cases, nonoperatively.All curative updates
- Coverage CriteriaClinical/Medical PolicyAbdominoperineal Resection (APR)This policy governs medical necessity, inpatient level of care, continued stay, discharge readiness, and documentation for open, laparoscopic, or robotic abdominoperineal resection with permanent end colostomy and perineal closure or flap reconstruction in adults 18 years and older.All curative updates
- Coverage CriteriaClinical/Medical PolicyAcute Aortic Syndrome Inpatient Admission and Level-of-Care ManagementMedical necessity criteria for acute inpatient admission, ICU and ward level-of-care assignment, continued stay, discharge readiness, and emergency repair or TEVAR for Curative commercial PPO and EPO members with acute aortic syndromes.All curative updates
- Coverage CriteriaClinical/Medical PolicyAcute Exacerbation of Chronic Obstructive Pulmonary DiseaseMedical-necessity criteria for outpatient treatment, observation, acute inpatient admission, level-of-care assignment, continued stay, and discharge readiness for Curative commercial members age 18 and older with acute COPD exacerbation, including acute hypercapnic respiratory failure treated with noninvasive or invasive ventilation.All curative updates
- Coverage CriteriaClinical/Medical PolicyAcute Heat Stroke Inpatient and Level-of-Care Coverage PolicyMedical-necessity criteria for acute inpatient admission, observation, outpatient management, intensive care, intermediate care, medical-surgical care, continued stay, and discharge readiness for exertional and classic heat stroke in Curative commercial members of all ages.All curative updates
- Coverage CriteriaClinical/Medical PolicyAdrenalectomy for Pheochromocytoma and Abdominal ParagangliomaThis policy governs medical necessity, inpatient level of care, continued-stay review, discharge readiness, documentation, and coding for laparoscopic, robotic, or open adrenalectomy for pheochromocytoma and resection of abdominal paraganglioma in adults and children.All curative updates
- Coverage CriteriaClinical/Medical PolicyAortic Root Replacement (Bentall Procedure)Governs medical necessity and inpatient level-of-care criteria for composite aortic root replacement and valve-sparing root replacement in adults, including elective and emergent cases such as acute type A dissection involving the root. Pediatric and congenital cases require physician review; isolated aortic valve replacement and transcatheter procedures are reviewed under the valve policy.All curative updates
- Coverage CriteriaClinical/Medical PolicyAtrial Fibrillation / Flutter - AcuteThis policy governs emergency department discharge, observation, acute inpatient admission, level-of-care assignment, continued stay, discharge readiness, and monitored initiation of selected antiarrhythmic drugs for adults with acute atrial fibrillation or atrial flutter. It applies to Curative commercial PPO and EPO members in fully insured, level-funded, and self-funded plans.All curative updates
- Coverage CriteriaClinical/Medical PolicyAutologous Breast Reconstruction with Abdominal Flaps (DIEP, SIEA, Free TRAM, and Pedicled TRAM)This policy governs medical necessity, inpatient level of care, continued-stay review, discharge readiness, documentation, and coding for immediate or delayed autologous breast reconstruction using DIEP, SIEA, free TRAM, or pedicled TRAM flaps in adults. Implant-based reconstruction, fat grafting, nipple reconstruction, and other procedures performed in outpatient settings are outside this policy.All curative updates
- Coverage CriteriaClinical/Medical PolicyBehavioral Health - TMS and ECT TherapiesThis policy establishes medical-necessity criteria for repetitive transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT), including initial, continuation, maintenance, and re-treatment courses. It applies to all plan types and treatment settings where these services are delivered, subject to device clearances, applicable state requirements, and parity rules.All curative updates
- Coverage CriteriaClinical/Medical PolicyBowel Obstruction - Small and Large BowelMedical necessity for acute inpatient admission, observation or outpatient care, level-of-care assignment, continued stay, discharge readiness, and related hospital services for adults with small or large bowel obstruction, acute colonic pseudo-obstruction, or ileus requiring hospital care.All curative updates
- Coverage CriteriaClinical/Medical PolicyBrain Metastases With Cerebral EdemaGoverns acute inpatient admission, level-of-care assignment, continued stay, and discharge for adult members with brain or leptomeningeal metastases complicated by symptomatic edema or related neurologic complications under Curative commercial PPO and EPO plans.All curative updates
- Coverage CriteriaClinical/Medical PolicyBronchopulmonary DysplasiaMedical necessity for continued NICU or special care nursery stays, level of care, discharge readiness, and readmission for respiratory decompensation in neonates and young infants with evolving or established bronchopulmonary dysplasia.All curative updates
- Coverage CriteriaClinical/Medical PolicyCardiac Tumor Excision (Including Atrial Myxoma)Inpatient medical-necessity criteria for surgical excision of primary intracardiac tumors, including atrial myxoma, papillary fibroelastoma, and selected malignant or metastatic cardiac tumors, for Curative commercial PPO and EPO members; thrombus, vegetation management, and pericardial disease are out of scope.All curative updates
- Coverage CriteriaClinical/Medical PolicyColectomy / Bowel ResectionThis policy governs inpatient admission, level-of-care assignment, continued stay, and discharge for open, laparoscopic, or robotic resection of the colon, rectum, or small bowel, with or without ostomy creation, for Curative commercial PPO and EPO plans. It applies to adults age 18 and older; pediatric bowel resection is reviewed by pediatric surgery.All curative updates
- Coverage CriteriaClinical/Medical PolicyColonoscopy Coverage and Medical NecessityCoverage criteria for screening, follow-on, surveillance, diagnostic, therapeutic, hereditary-syndrome, inflammatory bowel disease, and stoma colonoscopy in adults and members with qualifying risk factors or indications.All curative updates
- Coverage CriteriaClinical/Medical PolicyComputed Tomographic ColonographyThis policy governs coverage criteria for screening and diagnostic computed tomographic colonography (CTC, or virtual colonoscopy) in adults. It addresses medical necessity, repeat services, follow-up after CTC findings, documentation, coding, safety exclusions, and review requirements.All curative updates
- Coverage CriteriaClinical/Medical PolicyDME - Enteral and Parenteral SuppliesMedical-necessity review for home enteral nutrition formulas, supply kits, feeding tubes, pumps, and home parenteral nutrition solutions, additives, supplies, and pumps. Applies to all ages, subject to plan benefits, with individualized pediatric nutrition targets.All curative updates
- Coverage CriteriaClinical/Medical PolicyDecortication, Pleurectomy, and Surgical PleurodesisInpatient medical-necessity and level-of-care criteria for open or thoracoscopic decortication, pleurectomy, and surgical pleurodesis for Curative commercial PPO and EPO members, including empyema, trapped lung or fibrothorax, malignant pleural effusion, recurrent or persistent pneumothorax, and retained hemothorax.All curative updates
- Coverage CriteriaClinical/Medical PolicyDisseminated Intravascular CoagulationMedical necessity criteria for acute inpatient admission, observation or outpatient management, ICU and intermediate-level care, continued stay, and discharge readiness for Curative commercial members with disseminated intravascular coagulation or sepsis-induced coagulopathy; applies to all ages, with neonatal and obstetric DIC reviewed by a physician of the same or similar specialty.All curative updates
- Coverage CriteriaClinical/Medical PolicyEctopic Pregnancy - Ruptured or UnstableThis policy governs acute inpatient admission, observation, level-of-care, continued-stay, and discharge-readiness determinations for Curative commercial members with ectopic pregnancy, especially ruptured, hemodynamically unstable, surgically managed, or nontubal cases. Stable unruptured ectopic pregnancy managed medically or expectantly is addressed as observation or outpatient care.All curative updates
- Coverage CriteriaClinical/Medical PolicyF010. Myomectomy (Abdominal and Complex Laparoscopic)Inpatient medical-necessity criteria, level of care, continued stay, discharge readiness, documentation, and coding for abdominal and complex laparoscopic or robotic myomectomy in members seeking uterine preservation or future fertility.All curative updates
- Coverage CriteriaClinical/Medical PolicyF114. Corneal Transplantation (Keratoplasty) When Inpatient Care Is RequestedThis policy governs medical necessity for inpatient admission, continued stay, level of care, and discharge readiness when penetrating, anterior lamellar, or endothelial keratoplasty is requested. It applies to adults and children; the keratoplasty procedure itself is generally reviewed under the outpatient ophthalmology policy.All curative updates
- Coverage CriteriaClinical/Medical PolicyFemoral Shaft FractureGoverns acute inpatient admission, level of care, continued stay, and discharge readiness for Curative commercial members aged 18 years and older with closed femoral shaft fractures.All curative updates
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Tool Description
Search Curative 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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