Excellus_health_plan_inc Coverage Criteria
Latest Excellus_health_plan_inc coverage criteria updates17
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Home Non-Invasive Positive Pressure Ventilation (NIPPV) Devices for Respiratory Insufficiency and FailureMedical necessity criteria for home BPAP and non-invasive mechanical ventilation devices used for respiratory insufficiency or failure.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-20Breast Reconstruction Surgery and Prophylactic Breast Cancer Risk-Reducing MastectomyMedical-necessity coverage for reconstructive breast surgery during or after mastectomy and prophylactic risk-reducing mastectomy, including related reconstruction, symmetry procedures, prostheses, and treatment of post-mastectomy complications.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-20Focal Therapies for Prostate Cancer TreatmentThis policy addresses medical necessity for cryosurgery, HIFU, and other focal therapies for prostate cancer. Cryosurgery and HIFU may be appropriate for selected recurrent disease after radiation therapy when metastatic disease is absent; routine primary focal therapy and specified other modalities are investigational.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-07Experimental or Investigational ServicesThis policy determines whether services, devices, delivery systems, drugs, biological products, and procedures are experimental or investigational for a requested indication. Such services are excluded from coverage unless coverage is required by state or federal law.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-16Hyperbaric Oxygen Therapy (HBOT)This policy governs coverage determinations for topical and systemic hyperbaric oxygen therapy, identifying topical therapy as investigational and describing medically appropriate systemic indications, including criteria for selected diabetic lower-extremity wounds.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-16Laboratory Testing for Transplantation RejectionCoverage of gene-expression profiling and other laboratory or molecular tests used to evaluate transplant rejection or graft dysfunction, including medical-necessity criteria for AlloMap after heart transplantation and investigational classifications for several other tests.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-18Applied Behavior AnalysisMedical necessity review and coverage of Applied Behavior Analysis services for members with a DSM-5-TR diagnosis, including assessment, treatment, documentation, continued-therapy review, and provider requirements.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-21Dental and Oral Care under Medical PlansThis policy governs when dental and oral procedures may be covered under a member's medical/surgical contract rather than dental benefits. It addresses oral surgery, cyst removal, oral biopsies, accidental injury to sound natural teeth, and treatment of congenital anomalies or disease.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-19Ambulance: Land/GroundThis policy governs medical-necessity coverage criteria for emergency and non-emergent land/ground ambulance transportation, subject to New York State mandates and the member's contract.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-19Bulking Agents for Treatment of Urinary or Fecal IncontinenceThis policy evaluates the medical necessity of FDA-approved urethral bulking agents for urinary incontinence and identifies qualifying clinical indications, exclusions, and investigational treatments.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-19Interfacility Transfer of a Registered InpatientThis policy governs coverage of transferring a registered inpatient between acute care facilities for medically necessary specialized diagnostic or therapeutic services. It addresses the transferred admission and hospital stays, not the transportation service itself.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-16Cranial OrthoticsThis policy governs coverage of cranial orthotics, including helmets and cranial remodeling bands, for children with positional plagiocephaly or craniosynostosis. Coverage depends on clinical criteria, documented cranial asymmetry, prior treatment, surgical history where applicable, and the member’s contract benefits.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-22Aqueous Drainage Devices (Stents and Shunts) for GlaucomaCoverage of FDA-approved aqueous drainage devices, including shunts and micro-stents, for patients with glaucoma, including medically appropriate indications, investigational uses, and micro-stent criteria when performed with cataract surgery.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-22Brachytherapy After Breast-Conserving SurgeryThis policy governs coverage of accelerated partial breast irradiation using interstitial or balloon brachytherapy after breast-conserving surgery, including clinical criteria for medically appropriate use and circumstances considered not medically necessary or investigational. It also addresses intra-operative and electronic breast radiotherapy.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-22Brachytherapy or Radioactive Seed Implantation for Prostate CancerThis policy governs coverage of permanent LDR and temporary HDR brachytherapy for localized prostate cancer, including monotherapy and brachytherapy boost used with EBRT.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-20Chromosomal Microarray (CMA) Analysis for Prenatal Evaluation and Evaluation of Patients with Developmental Delay/Intellectual Disability or Autism Spectrum DisorderCoverage of comparative genomic hybridization/chromosomal microarray analysis for prenatal diagnostic evaluation and for children with developmental delay or intellectual disability, autism spectrum disorder, or multiple nonspecific anomalies, including genetic counseling, qualified laboratory, documentation, and medical-necessity requirements.All excellus_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-16Erectile DysfunctionThis policy governs the medical appropriateness of diagnostic procedures and treatment modalities for individuals with erectile dysfunction, including appropriate diagnostic testing, non-covered services, and treatment coverage requirements.All excellus_health_plan_inc updates
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Tool Description
Search Excellus_health_plan_inc 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.
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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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