Johns_hopkins_health_plans Coverage Criteria
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Latest Johns_hopkins_health_plans coverage criteria updates8
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Pediatric Feeding Programs (Pediatric Intensive Feeding Programs)Defines medical necessity criteria, evaluation requirements, and coverage stance for pediatric intensive feeding day and inpatient programs for children (ages 1–18) when benefits exist under the member's contract.All johns_hopkins_health_plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Prostate Artery EmbolizationThis policy governs coverage and medical necessity criteria for prostate artery embolization (PAE) to treat benign prostatic hyperplasia (BPH) and related lower urinary tract symptoms for members of Johns Hopkins Health Plans lines of business.All johns_hopkins_health_plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Remote Patient Monitoring (RPM) — Coverage CriteriaGoverns coverage and clinical criteria for remote physiologic monitoring services (collection of physiologic data using devices) for Johns Hopkins Health Plans participating lines of business.All johns_hopkins_health_plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Cell and Gene Therapy Access Model - PPMCOGoverns prior authorization, clinical criteria, authorized treatment centers, and coverage processes for CASGEVY and LYFGENIA under the Maryland Cell and Gene Therapy Access Model as applied by Johns Hopkins Health Plans (Priority Partners Managed Care Organization). Affects members with sickle cell disease seeking these gene therapies and providers/ATCs administering them.All johns_hopkins_health_plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Gender‑Affirming Treatment & Procedures - EHPThis policy governs authorization and coverage criteria for gender-affirming medical and surgical treatments and adjunctive procedures for members of Johns Hopkins Employer Health Programs (EHP). It describes diagnostic requirements, age-specific criteria, covered procedures, exclusions, and related considerations (e.g., fertility, hormones).All johns_hopkins_health_plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Solid Organ Transplantation — Coverage CriteriaDefines Johns Hopkins Health Plans coverage criteria, requirements, and coding guidance for solid organ transplantation services and related devices when benefits are provided under a member's contract; applies to multiple participating organizations listed by the plan.All johns_hopkins_health_plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Infertility Treatment and Fertility PreservationDefines medical necessity criteria, covered services, limitations, and investigational exclusions for infertility evaluation, treatment, and fertility preservation across Johns Hopkins Health Plans lines of business where member benefits provide coverage.All johns_hopkins_health_plans updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Stretching Devices for the Treatment of Joint Stiffness and ContracturePolicy governing coverage and medical necessity criteria for low-load prolonged-duration stretch (LLPS)/dynamic and static progressive stretch (SPS) splinting devices and patient-actuated serial stretch (PASS) devices for members of Johns Hopkins Health Plans participating organizations.All johns_hopkins_health_plans updates
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Tool Description
Search Johns_hopkins_health_plans 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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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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