Independent Health Coverage Criteria
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Latest Independent Health coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Prior Authorization and Coverage Criteria for Part D Formulary Specialty DrugsDefines prior authorization requirements and clinical criteria for outpatient prescription specialty drugs on Independent Health Medicare Advantage Part D formularies, including documentation, prescriber restrictions, testing requirements, coverage durations, and reauthorization rules.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Medicare Part D Prior Authorization Criteria — 2026 Formulary (Medicare C‑SNP Part D)Prior authorization requirements for drugs on Independent Health's 2026 Medicare Advantage C‑SNP Part D formulary describing clinical, prescriber, age, and documentation criteria for coverage decisions.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Medicare Part D Formulary (Assure Advantage® HMO C-SNP) — Drug List / Coverage CriteriaThis document is Independent Health's Part D drug formulary for the Assure Advantage® (HMO C-SNP) plan and governs which prescription drugs are covered, any coverage restrictions, and how members and prescribers may request exceptions. It affects plan members, prescribers, and network pharmacies using Independent Health's Medicare Advantage Part D benefit.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Medicare Advantage Part D Formulary (Drug List) — Coverage CriteriaThis document governs the Independent Health Medicare Advantage Part D drug formulary — which drugs are covered, applicable coverage restrictions (prior authorization, quantity limits, step therapy), and how members and prescribers can request exceptions or transition supplies.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-11-01Transperineal Placement of Biodegradable Material for Prostate Cancer (Barrigel)Defines Independent Health's medical necessity criteria and coverage stance for transperineal placement of the biodegradable rectal spacer Barrigel in members undergoing external radiotherapy for localized prostate cancer; applies to commercial, Medicare Advantage, and specified state plans.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-01Measurable Residual Disease Assessment for Hematological Cancers - clonoSEQDefines medical necessity and coverage criteria for clonoSEQ NGS-based MRD testing in members with B-cell ALL, CLL, and multiple myeloma across Independent Health lines of business; affects ordering providers and billing for covered plans.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-04-01Gastroparesis Treatments - Gastric Electrical Stimulation and Gastric Peroral Endoscopic Myotomy (G-POEM)Medical necessity criteria, coverage stance, and pre-authorization requirements for gastric electrical stimulation (Enterra) and Gastric Peroral Endoscopic Myotomy (G-POEM) for treatment of gastroparesis across specified Independent Health lines of business.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-03-01Skin SubstitutesMedical necessity criteria and coverage stance for bioengineered skin substitute products used as adjuncts to standard wound care across Independent Health lines of business (Commercial, Medicare Advantage, MediSource/Connect, Child Health Plus, Essential Plan).All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-03-01Skin SubstitutesMedical necessity criteria and coverage policy for use of skin substitutes for wound care across Independent Health lines of business (Commercial, Medicare Advantage, MediSource, Essential Plan, Child Health Plus, and others). Affects providers requesting coverage for bioengineered tissue products.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-09-01Shoulder Joint ReplacementsMedical necessity criteria and prior authorization requirements for shoulder joint replacement procedures (including total, hemi, and reverse shoulder arthroplasty) for Independent Health members across Commercial, Medicare Advantage, MediSource, Child Health Plus, and Essential Plan lines of business.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-09-01Shoulder Joint ReplacementsMedical necessity criteria and preauthorization requirements for shoulder joint replacement procedures (hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, and revision) for members covered under Independent Health lines of business.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-09-01Shoulder Joint ReplacementsMedical necessity criteria and preauthorization requirements for shoulder joint replacement procedures (hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, and revision) for Independent Health lines of business including Commercial, Medicare Advantage, MediSource products, Child Health Plus, and Essential Plan.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-05-01Long Term Acute Care (LTAC)Defines Independent Health's medical necessity criteria and pre-authorization requirement for inpatient services in long-term acute care (LTAC) facilities across specified lines of business.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-05-01Long Term Acute Care (LTAC)Defines Independent Health's medical necessity criteria and pre-authorization requirements for inpatient services provided in Long Term Acute Care facilities; applies to specified lines of business and plans.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-05-01Preimplantation Genetic Testing PolicyDefines Independent Health's medical necessity criteria for preimplantation genetic diagnostic testing as an adjunct to in vitro fertilization (IVF), lists populations and product lines where covered or excluded, and specifies prior authorization and documentation responsibilities.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-02-02Oral Immunotherapy (OIT) for the Treatment of Food AllergyDefines Independent Health's medical necessity criteria for oral immunotherapy for food allergy across applicable lines of business (commercial, Medicare Advantage, MediSource/State products). It specifies coverage when FDA-approved therapy is used and treats other OIT as investigational.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-11-01Corticosteroid-Eluting (Mometasone Furoate) Implants for the Treatment of Recurrent Nasal Polyps - Sinuva® and Propel®Medical necessity criteria and coverage stance for Sinuva® and Propel® sinus implants for treatment of recurrent nasal polyps/chronic rhinosinusitis for Independent Health lines of business.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-07-01Hicon (Sodium Iodide I-131) therapy coverage criteriaMedical necessity criteria and coverage stance for a single administration of Hicon (radioactive iodide I-131) for treatment of hyperthyroidism and differentiated thyroid carcinoma across applicable Independent Health lines of business.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-07-01Hicon® (Sodium Iodide I-131) therapy coverageDefines medical necessity criteria and coverage limits for a single administration of Hicon® (sodium iodide I-131) for hyperthyroidism and differentiated thyroid carcinoma across Independent Health lines of business and products.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-07-01Xofigo (radium Ra 223 dichloride) for Treatment of Castration-Resistant Prostate CancerDefines Independent Health's medical necessity and pre-authorization criteria for coverage of Xofigo in adults with castration-resistant prostate cancer (CRPC) with symptomatic bone metastases and no known visceral disease; applies to Medicare Advantage, commercial, MediSource, and Essential Plan.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-07-01Zevalin (ibritumomab tiuxetan) PolicyDefines medical necessity criteria, dosing, and prior authorization requirement for Zevalin (ibritumomab tiuxetan) for treatment of non-Hodgkin's lymphoma across commercial, Medicare Advantage, MediSource, and Essential Plan lines of business.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-08-01Monitored Anesthesia Care for Gastrointestinal ProceduresDefines Independent Health's medical necessity criteria for use of monitored anesthesia care (MAC) during gastrointestinal endoscopic procedures (e.g., colonoscopy, endoscopy) across Commercial, Self-Funded, MediSource, MediSource Connect, Child Health Plus, Essential Plan, and Medicare Advantage lines of business. Specifies documentation, audit, and denial conditions; pre-authorization is not required.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-11-01Impeller Driven Percutaneous Ventricular Assist Devices (Impella)Medical necessity criteria and coverage stance for use of impeller-driven percutaneous ventricular assist devices (e.g., Impella systems, TandemHeart) for Independent Health members across applicable lines of business.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-08-01Lutetium Lu 177 Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto)Medical necessity and coverage criteria for Lutetium Lu 177 Dotatate (Lutathera) for somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto) for PSMA-positive metastatic castration-resistant prostate cancer (mCRPC); applies to Independent Health lines of business noted in the policy.All Independent Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-08-01Lutetium Lu 177 Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto)Medical necessity criteria, dosing, and pre-authorization requirements for Lutathera for somatostatin receptor-positive GEP-NETs and Pluvicto for PSMA-positive metastatic castration-resistant prostate cancer; applies to Independent Health commercial, Medicare Advantage, MediSource and related lines of business.All Independent Health updates
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Tool Description
Search Independent Health 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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