Highmark Blue Cross Blue Shield Wny Coverage Criteria
- Highmark Blue Cross Blue Shield Wny prior authorization
- Highmark Blue Cross Blue Shield Wny timely filing
- All Highmark Blue Cross Blue Shield Wny policy updates
Latest Highmark Blue Cross Blue Shield Wny coverage criteria updates7
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Lymphedema surgery (NLN position statement) — Coverage CriteriaThis document summarizes the National Lymphedema Network's position on surgical management of primary and secondary lymphedema, including physiologic, reductive, and immediate/early reconstruction procedures, and addresses appropriate patient selection and integration with conservative therapy.All Highmark Blue Cross Blue Shield Wny updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-28Clinical Utilization Management Guidelines (CUMG) for DME and related servicesA listing and adoption notice of Clinical Utilization Management Guidelines Highmark BCBSWNY uses for Medicaid Managed Care (MMC), HARP, and Child Health Plus (CHPlus) programs; includes many DME-related guideline titles. Affects providers submitting requests for medical necessity review and coverage under those programs.All Highmark Blue Cross Blue Shield Wny updates
- Coverage CriteriaClinical/Medical PolicyAutologous fat grafting to the breast — coverage criteriaPolicy governing use, coverage rationale, and coding guidance for autologous fat grafting (fat transfer/lipoinjection) for breast reconstruction, contour deformities, asymmetry, hypoplasia, and restoration of irradiated skin in adults.All Highmark Blue Cross Blue Shield Wny updates
- Coverage CriteriaClinical/Medical PolicyClinical Utilization Management Guidelines (DME and other services)A catalogue of Clinical Utilization Management (CUMG) guidelines adopted by Highmark BCBS for Medicaid Managed Care, HARP, Child Health Plus, and Essential Plan members; includes multiple DME-related guideline titles and indicates use of MCG Care Guidelines where applicable.All Highmark Blue Cross Blue Shield Wny updates
- Coverage CriteriaClinical/Medical PolicyClinical Utilization Management Guidelines — Durable Medical Equipment (DME) coverage criteriaLists Clinical Utilization Management (UM) Guidelines adopted by Highmark BCBS relevant to Medicaid Managed Care (MMC), HARP, Child Health Plus (CHPlus), and Essential Plan members; intended for providers and staff involved in medical necessity and utilization review processes.All Highmark Blue Cross Blue Shield Wny updates
- Coverage CriteriaClinical/Medical PolicyManagement and Coverage Criteria for Breast Implant–Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)Clinical guidance on diagnosis, evaluation, and surgical management (implant removal and capsulectomy) for suspected or confirmed BIA-ALCL affecting patients with breast implants; intended for clinicians and payers involved in care decisions.All Highmark Blue Cross Blue Shield Wny updates
- Coverage CriteriaClinical/Medical PolicySurgical treatment of skin redundancy following obesity or massive weight loss (abdominoplasty, panniculectomy, related body-contouring procedures)Defines recommended insurance coverage criteria distinguishing reconstructive (medically necessary) versus cosmetic procedures for removal of excess skin and fat following obesity or massive weight loss, with procedure definitions, example diagnostic and procedure codes, and guidance on when procedures are considered reconstructive vs cosmetic.All Highmark Blue Cross Blue Shield Wny updates
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Tool Description
Search Highmark Blue Cross Blue Shield Wny 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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