Kaiser Permanente Coverage Criteria
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Latest Kaiser Permanente coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-12-01Clinical Review Criteria — Radiopharmaceuticals (Lutathera and Pluvicto)Clinical review criteria governing medical necessity determinations for Lutathium Lu 177 dotatate (Lutathera) for somatostatin receptor‑positive GEP‑NETs and Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) for metastatic castration‑resistant prostate cancer, for use by Kaiser Foundation Health Plan of Washington providers and members.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Ambulatory Surgery Center (ASC) - Site of Care PolicyDefines site-of-care review and medical necessity criteria for elective outpatient surgical procedures to determine when procedures should occur in an ASC versus a hospital outpatient department; applies to Kaiser Foundation Health Plan of Washington members and their providers in specified Washington counties.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Positron Emission Tomography (PET) Scan Clinical Review CriteriaClinical criteria governing medical necessity and use of PET scans for Kaiser Foundation Health Plan of Washington members, intended for providers and internal use to guide coverage decisions across oncologic and certain non-oncologic indications.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-03Endovenous Procedures for Varicose VeinsClinical coverage criteria for endovenous ablation, sclerotherapy, phlebectomy, and related procedures for symptomatic varicose veins used by Quality Resource Management staff to determine medical necessity for members in the Georgia region.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-16Clinical Review Criteria — Sacroiliac Joint Procedures for Pain (SI joint injections, neurotomy/RFA, and fusion)Clinical review criteria for sacroiliac (SI) joint injections, neurotomy (RFA), and fusion covering Kaiser Foundation Health Plan of Washington members and providers. Applies to Medicare and non‑Medicare members as specified.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-01Clinical Review Criteria — Physical Therapy ServicesDefines medical necessity, coverage, and exclusions for outpatient, inpatient, home, habilitative, and rehabilitative physical therapy services for Kaiser Foundation Health Plan of Washington members and providers.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-01Clinical Review Criteria — Physical Therapy ServicesDefines medical necessity, coverage criteria, exclusions, and code guidance for physical therapy and related rehabilitative services for Kaiser Foundation Health Plan of Washington members.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-01Outpatient Occupational and Physical Therapy Services — Clinical Review CriteriaClinical review criteria governing medical necessity, coverage, and coding for outpatient occupational and physical therapy (including habilitative services) for Kaiser Foundation Health Plan of Washington members; affects providers requesting therapy services and internal utilization management staff.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-01Speech Language TherapyDefines medical necessity criteria, continuation requirements, exclusions, and applicable CPT/HCPCS codes for outpatient, home, inpatient, voice, auditory/aural, and swallowing/feeding speech-language therapy services for Kaiser Foundation Health Plan of Washington members.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-10Synucleinopathies Testing for Movement Disorders (Syn-One)Clinical review criteria for use of Syn-One skin biopsy testing to aid diagnosis of synucleinopathies for Kaiser Foundation Health Plan of Washington members; covers Medicare and non‑Medicare determinations, documentation, and authorization guidance for movement disorder neurologists.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Advanced Care at Home (ACAH) — Coverage CriteriaDefines clinical review criteria, coverage requirements, services, and limitations for Kaiser Permanente Advanced Care at Home (ACAH) for Medicare and non‑Medicare members within the plan's service area.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-11-05Massage therapy coverageRules for when massage therapy is considered medically necessary or not for Kaiser Foundation Health Plan of Washington members, including Medicare-specific guidance and applicable CPT codes. Affects clinicians ordering or providing massage services and utilization reviewers.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-03Outpatient Speech/Language Therapy Services Coverage CriteriaClinical review criteria governing medical necessity and coverage of outpatient speech, language, voice, auditory/aural rehabilitation, and swallowing/feeding therapy services for Kaiser Foundation Health Plan of Washington members.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-05Kaiser Foundation Health Plan of Washington Clinical Review Criteria for Durable Medical Equipment and ProstheticsDefines medical necessity criteria, required documentation, exclusions, code guidance, and specific prosthetic/orthotic coverage requirements for Kaiser Foundation Health Plan of Washington members (Medicare and non-Medicare), including alignment with state law SHB 1669 effective 1/1/2026.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-01Capsule Endoscopy (including Patency Capsule / PillCam / PillCam SB / Colon Capsule)Clinical review criteria governing medical necessity determinations for capsule endoscopy (small bowel and colon) and patency capsule use for Kaiser Foundation Health Plan of Washington members; includes Medicare/LCD references and notes MCG use for non-Medicare determinations. Lists applicable CPT codes and documentation requirements.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-01Capsule endoscopy (small bowel and patency capsule) coverage criteriaClinical review criteria governing medical necessity determinations for capsule endoscopy (including PillCam/PillCam SB and Given/AGILE patency system) for Kaiser Permanente Washington members; guidance differs for Medicare vs non‑Medicare members.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-01Transcranial Magnetic Stimulation (TMS) for Treatment-Resistant DepressionClinical review criteria for use of repetitive and deep transcranial magnetic stimulation (rTMS/dTMS) for major depressive disorder and related indications, governing coverage determinations for Kaiser Foundation Health Plan of Washington members and providers.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-04Clinical Review Criteria: Mobility Assistive Devices (Manual & Power Wheelchairs, Scooters, Accessories)Clinical review criteria governing medical necessity, documentation, and coverage for manual wheelchairs, power wheelchairs, scooters, and associated special parts for Kaiser Foundation Health Plan of Washington members and treating providers.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Cardiac CT (CCTA), Coronary Calcium Scoring, FFR-CT, and AI-enabled CT Plaque Analysis — Clinical Review CriteriaClinical review criteria governing medical necessity determinations for cardiac computed tomography studies (including coronary CT angiography, coronary artery calcium scoring, CT-based FFR, and AI-enabled quantitative coronary plaque analysis) for Kaiser Foundation Health Plan of Washington members and providers.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Clinical Review Criteria — Cervical Spine MRIMedical necessity criteria and authorization guidance for cervical spine MRI for Kaiser Foundation Health Plan of Washington members, covering indications, required conservative therapy, red flags, and coding; applies to providers requesting MRI services for covered members.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-27Ultrasound and Electric Osteogenesis StimulatorsPolicy governs medical necessity and coverage criteria for low-intensity pulsed ultrasound (LIPUS) and electric bone stimulators for fracture healing and nonunion in members of the Kaiser Permanente Georgia region.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-06-01Clinical Review Criteria Total Hip ArthroplastyDefines Kaiser Permanente Washington clinical review and medical necessity criteria for total hip arthroplasty (including inpatient vs ambulatory level of care, indications such as degenerative hip disease, avascular necrosis, inflammatory arthritis, revisions, and contraindications), required documentation, and applicable CPT codes.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-06-01Kaiser Foundation Health Plan of Washington - Vipivotide Tetraxetan and Dotatate Clinical Review CriteriaClinical review criteria for medical necessity determinations for Lutetium Lu 177 dotatate (Lutathera) for somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs) and Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) for progressive metastatic castration-resistant prostate cancer (mCRPC) for Kaiser Foundation Health Plan of Washington members (non-Medicare criteria applied when Medicare coverage guidance absent).All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-05-01Clinical Review Criteria — Thoracic Spine MRIDefines medical necessity criteria and authorization guidance for MRI of the thoracic spine for Kaiser Foundation Health Plan of Washington members; applies to providers requesting thoracic spine MRI services for covered members.All Kaiser Permanente updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-10-01Total Knee Arthroplasty (TKA) clinical review/medical necessityDefines Kaiser Permanente Washington clinical review criteria for total knee and unicompartmental knee arthroplasty (including revisions) for inpatient vs ambulatory level-of-care determinations and medical necessity criteria for non‑Medicare members. Also lists applicable CPT/HCPCS procedure codes and documentation requirements.All Kaiser Permanente updates
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Tool Description
Search Kaiser Permanente 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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