Mhn Coverage Criteria
Latest Mhn coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Clinical Policy: Liposuction for LipedemaDefines medical necessity criteria and coding guidance for liposuction as a treatment for lipedema for health plans affiliated with Centene Corporation; applicable to providers requesting coverage for members with lipedema.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Tandem TransplantMedical necessity criteria and coverage guidance for planned sequential (tandem) high-dose therapy with hematopoietic cell transplant, primarily autologous transplants (and select autologous→allogeneic sequences) for specific malignancies; applies to members/enrollees of the payer.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive DisorderMedical necessity criteria, coding, and coverage stance for use of deep transcranial magnetic stimulation to treat obsessive-compulsive disorder for members/enrollees of the payer.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Donor Lymphocyte InfusionMedical necessity and coverage criteria for donor lymphocyte infusion following allogeneic hematopoietic stem cell transplantation for relapsed or high-risk hematologic malignancies; applies to non-Medicare health plans affiliated with the payer.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Pediatric Kidney TransplantMedical necessity criteria and coverage guidance for pediatric (age <18) kidney transplantation for non‑Medicare health plans affiliated with Centene, including candidate eligibility and contraindications.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Transcranial Magnetic Stimulation (TMS) for Treatment‑Resistant Major DepressionDefines medical necessity, coverage criteria, contraindications, and review pathways for rTMS, dTMS, and iTBS for adults and adolescents with treatment‑resistant major depressive disorder for Centene‑affiliated health plans.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Biofeedback for Behavioral Health DisordersDefines medical necessity criteria, limits, and review process for biofeedback used as an adjunctive treatment for anxiety disorders and PTSD for members/enrollees of Centene-affiliated behavioral health plans.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Total Parenteral Nutrition and Intradialytic Parenteral NutritionDefines medical necessity criteria, coverage durations, and coding implications for TPN and IDPN for members/enrollees of the payer; applies to clinicians and billing staff requesting authorization or adjudicating claims.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Holter MonitorsMedical necessity guidelines for ambulatory ECG Holter monitoring up to 48 hours for adults and pediatric members/enrollees, and indications that justify coverage; longer-term monitoring is addressed separately via clinical decision support.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Dental Anesthesia (PDF)Defines medical necessity criteria for intravenous moderate sedation and deep sedation/general anesthesia for dental procedures in inpatient, ambulatory surgery center, community clinic or dental office settings; references regulatory and facility requirements and coding implications.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Proton and Neutron Beam TherapiesDefines medical necessity criteria and guidance for coverage of proton beam therapy (PBT) and neutron beam therapy (NBT) for members/enrollees of Centene-affiliated health plans; intended for clinicians and prior authorization reviewers.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Asthma Remediation Community Support — Coverage CriteriaDefines coverage, provider requirements, allowable interventions, eligibility, lifetime maximums, and restrictions for Asthma Remediation services for Medi-Cal members served by the plan in California (Imperial County local context noted).All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Transitional Rent (Community Supports) — Coverage CriteriaDefines eligibility, provider and plan responsibilities, settings, documentation, authorization processes, and limits for Transitional Rent rental assistance as a Medi‑Cal Community Supports service affecting members and contracted providers in the plan network.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-16Asthma Remediation Community Support — Coverage CriteriaDefines coverage, eligibility, allowable services, limits, and operational requirements for Asthma Remediation Community Support for Medi‑Cal members in Imperial County served by CHPIV/Health Net.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Brensocatib (Brinsupri) — Coverage Criteria for Non‑Cystic Fibrosis BronchiectasisDefines medical necessity criteria, authorization, and dosing for brensocatib (Brinsupri) for commercial, HIM, and Medicaid members and specifies requirements for prior authorization and continued therapy for patients age ≥12.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Clinical Policy: Paltusotine (Palsonify)Defines medical necessity criteria, dosing limits, prior authorization expectations, and approval durations for Palsonify (paltusotine) for adult members with acromegaly across Commercial, HIM, and Medicaid lines of business.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Dordaviprone (Modeyso) for diffuse midline gliomaDefines medical necessity criteria, dosing, and prior authorization requirements for Modeyso (dordaviprone) for members across Commercial, HIM, and Medicaid lines of business, focused on treatment of diffuse midline glioma with H3 K27M mutation. Applies to providers submitting requests for initial and continuation therapy.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Gemcitabine Intravesical System (Inlexzo)This policy describes medical necessity criteria, dosing, and coding for Inlexzo (gemcitabine intravesical system) for treatment of BCG-unresponsive non-muscle invasive bladder cancer and defines coverage and documentation requirements for providers and health plans affiliated with Centene.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Imlunestrant (Inluriyo) coverage for ER+/HER2- ESR1-mutated advanced/metastatic breast cancerDefines medical necessity and prior authorization requirements for Inluriyo (imlunestrant) for adults with ER-positive, HER2-negative, ESR1-mutated advanced or metastatic breast cancer after progression on endocrine therapy; applies to commercial, HIM, and Medicaid lines of business.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Imlunestrant (Inluriyo) — Coverage CriteriaAll mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Nemolizumab-ilto (Nemluvio) Coverage CriteriaClinical policy governing medical necessity and coverage-related information for nemolizumab-ilto (Nemluvio) for treatment of prurigo nodularis and atopic dermatitis; applies to the Health Plan's members and providers administering biologic therapy.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Remibrutinib (Rhapsido) — Coverage and Medical Necessity Criteria for Chronic Spontaneous UrticariaCoverage and medical necessity criteria for remibrutinib (Rhapsido) for treatment of chronic spontaneous urticaria (CSU) in adults; governs Commercial, HIM, and Medicaid lines of business for the payer.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Rilzabrutinib (Wayrilz) — Coverage Criteria for Immune ThrombocytopeniaDefines medical necessity and prior authorization criteria for rilzabrutinib (Wayrilz) for adults with persistent or chronic immune thrombocytopenia (ITP) across commercial, HIM, and Medicaid lines of business.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Zongertinib (Hernexeos) — Coverage Criteria for HER2‑mutant NSCLCMedical necessity and prior authorization criteria for zongertinib (Hernexeos) for adults with unresectable or metastatic nonsquamous NSCLC harboring HER2 (ERBB2) activating mutations; applies to Centene-affiliated health plans including Commercial, HIM, and Medicaid.All mhn updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01PanniculectomyDefines medical necessity criteria and coding guidance for panniculectomy for members/enrollees of health plans affiliated with Centene Corporation. Applies to providers requesting coverage for panniculectomy procedures.All mhn updates
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Tool Description
Search Mhn 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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