Healthfirst Coverage Criteria
Latest Healthfirst coverage criteria updates10
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Diagnostic Testing of Iron Homeostasis and MetabolismDefines medical coverage criteria and clinical background for laboratory testing of iron status (serum ferritin, transferrin/transferrin saturation, and related assays) including indications, limitations, and excluded tests for Healthfirst members.All Healthfirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Nerve Fiber Density TestingThis policy governs coverage criteria for epidermal and sweat-gland nerve fiber density testing (skin biopsy with IENF/ENFD and SGNFD) for evaluation of small-fiber neuropathy and related indications for Healthfirst members.All Healthfirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Testosterone TestingClinical coverage criteria and scientific background for laboratory measurement of testosterone and related hormones, governing when testing is covered for Healthfirst members and clinical recommendations for providers.All Healthfirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Diagnosis of VaginitisCoverage and clinical guidance for laboratory and point-of-care testing to diagnose causes of vaginitis (BV, vulvovaginal candidiasis, and trichomoniasis) for symptomatic individuals; describes which tests meet or do not meet coverage criteria.All Healthfirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Human Immunodeficiency Virus (HIV) testing and resistance evaluationDefines coverage criteria for HIV screening, confirmatory testing, nucleic acid testing, viral load monitoring, and genotypic/phenotypic resistance testing for members, including indications, limitations, and testing frequency considerations.All Healthfirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Prescription Medication and Illicit Drug Testing in the Outpatient SettingDefines coverage criteria, limitations, and documentation/reimbursement rules for outpatient presumptive and definitive drug testing (primarily urine/oral fluid) for clinical purposes; applies to Healthfirst members and outpatient providers in North Carolina. This part covers indications, specimen types, frequency limits, and prohibited testing practices.All Healthfirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-05-01Diagnosis of Idiopathic Environmental IntoleranceDefines coverage stance for laboratory and diagnostic testing related to idiopathic environmental intolerance (IEI, formerly multiple chemical sensitivity) and describes which tests do not meet coverage criteria; intended for providers and claims reviewers under Healthfirst benefits.All Healthfirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-05-01Vitamin B12 and Methylmalonic Acid TestingDefines coverage criteria for serum total vitamin B12 and methylmalonic acid (MMA) testing, including indications, limitations, and tests that do not meet coverage criteria; applies to Healthfirst members as described in the policy.All Healthfirst updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-10-01Exon-skipping therapies for Duchenne muscular dystrophy (eteplirsen, golodirsen, casimersen, viltolarsen)Defines prior authorization, medical necessity, dosing, monitoring, billing, and coverage criteria for exon-skipping antisense oligonucleotide therapies for patients with Duchenne muscular dystrophy (DMD) within Healthfirst plans.All Healthfirst updates
- Coverage CriteriaClinical/Medical PolicyChapter 15 - Covered Medical and Other Health Services (Medicare Part B coverage criteria)Governs Medicare Part B coverage categories, rules for when Part B expenses are considered incurred, and specific provisions for items and services (e.g., surgery/childbirth, custom-made durable items). Affects providers billing Medicare Part B and suppliers of covered items.All Healthfirst updates
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Tool Description
Search Healthfirst 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.
Coverage Criteria by Payer
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Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
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