Moda Health Coverage Criteria
Latest Moda Health coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Breast PumpsThis policy governs Moda Health medical-necessity coverage for manual, electric, and hospital-grade breast pumps. Hospital-grade pump rental is covered only when specified clinical criteria, prescription, and contracted DME-provider requirements are met.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Corneal Collagen Cross-linking for Treatment of KeratoconusPolicy governing coverage and prior authorization requirements for corneal collagen cross-linking (CXL) to treat progressive keratoconus or corneal ectasia after refractive surgery for Moda Health members and providers.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Continuous Glucose Monitoring (CGM)Defines Moda Health coverage, prior authorization information, and clinical criteria for short-term diagnostic and long-term therapeutic use of FDA‑approved continuous glucose monitoring systems for members with diabetes.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-05Cosentyx (secukinumab) (Subcutaneous/Intravenous) — Prior Authorization and Medical NecessityDefines prior authorization, dosing limits, initial and renewal authorization periods, and medical necessity criteria for Cosentyx (secukinumab) for Moda Health members across labeled indications. Applies to providers requesting coverage for subcutaneous and intravenous formulations.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-05Denosumab (Prolia, Xgeva, biosimilars) — medical necessity and prior authorization criteriaMedical necessity, dosing limits, authorization periods, and coverage criteria for denosumab products for members in scope of Moda Health. Applies to providers requesting prior authorization for denosumab formulations listed in the policy.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Blepharoplasty and Brow Ptosis RepairDefines Moda Health medical necessity and coverage criteria, required documentation, and covered/not-covered CPT and ICD-10 codes for eyelid (blepharoplasty) and brow ptosis procedures for enrolled members.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Lumizyme (alglucosidase alfa) (Intravenous)Defines Moda Health prior authorization, dosing limits, medical necessity criteria, renewal conditions, and billing codes for intravenous Lumizyme (alglucosidase alfa) for treatment of Pompe disease.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-03Cimzia (certolizumab pegol) (Subcutaneous) — Prior Authorization and Coverage CriteriaDefines Moda Health prior authorization, dosing limits, length of authorization, and medical necessity criteria for Cimzia (certolizumab pegol) for multiple indications (e.g., RA, Crohn's disease, PsA, AS, pJIA). Applies to providers requesting coverage for members under Moda Health plans.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-03Cinqair (reslizumab) (Intravenous)Policy M-P0273 defines prior authorization, dosing limits, initial and renewal medical necessity criteria, contraindicated concomitant therapies, and administration dosing for Cinqair (reslizumab) for Moda Health members.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-03Cerezyme (imiglucerase) (Intravenous) — Coverage CriteriaPolicy governing prior authorization, dosing limits, indications, and renewal criteria for intravenous Cerezyme (imiglucerase) for members covered by Moda Health.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Balloon Dilation of the Eustachian TubeDefines Moda Health coverage, medical necessity criteria, exclusions, required documentation, and coding for balloon dilation of the eustachian tube (BDET) in adults; applies to providers requesting prior authorization for members.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Chiropractic ServicesDefines Moda Health coverage, medical necessity criteria, exclusions, and prior authorization information for chiropractic services for members with applicable benefits.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Durable Medical Equipment (DME) General PolicyDefines Moda Health's coverage, medical necessity criteria, documentation and exclusions for durable medical equipment supplied for home use; applies to Moda Health members and providers submitting DME requests for benefit determination.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Wearable Cardiac Defibrillators (WCD) Coverage CriteriaCriteria and coverage policy for wearable (vest-like) external cardiac defibrillators and related AED devices for adult members, including prior authorization information and applicable billing codes for Moda Health.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-02Myobloc® (rimabotulinumtoxinB) — Intramuscular/Intradermal/IntraglandularDefines prior authorization, dosing limits, initial and renewal medical necessity criteria for rimabotulinumtoxinB (Myobloc) for intramuscular/intradermal/intraglandular use affecting providers seeking coverage for adult indications.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Acupuncture — Coverage CriteriaDefines Moda Health coverage, criteria, and coding for acupuncture when listed as a covered benefit and administered by a legally qualified acupuncturist; applies to plan members whose benefit includes acupuncture. Specifies covered indications, limits, renewal requirements, and excluded indications and codes.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Applied Behavior AnalysisDefines medical necessity, authorization, documentation, and clinical criteria for provision of Applied Behavior Analysis services for individuals diagnosed with Autism Spectrum Disorder; applicable to providers requesting coverage from Moda Health.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Coordinated Specialty Programs (EASA, IOSS, IIBHT, ACT)Defines medical necessity criteria, prior authorization information, and covered CPT/HCPCS codes for coordinated specialty behavioral health programs (EASA, ACT, IOSS, IIBHT) offered under Moda Health; applies to providers and programs delivering these services in accordance with referenced Oregon administrative rules.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-02Azedra (iobenguane I-131) (Intravenous) coverage criteriaDefines Moda Health coverage, billing limits, and medical necessity criteria for Azedra (iobenguane I-131) for patients with pheochromocytoma/paraganglioma and related neuroendocrine adrenal tumors; affects providers submitting claims and seeking prior authorization for doses. Pre-payment claim edits apply; prior authorization criteria noted but PA does not apply for this policy for payment edits.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-02Hicon® (Sodium Iodide I-131) (Oral) coverage criteriaDefines Moda Health's medical necessity, dosing limits, billing codes, and authorization rules for oral Hicon (sodium iodide I-131) for hyperthyroidism and thyroid carcinoma; applies to Moda members and providers submitting claims. Prior authorization criteria do not apply, but pre-payment claims edits and PA validity rules are included.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-01Anesthesia for Routine Gastrointestinal Endoscopic ProceduresDefines Moda Health coverage criteria for anesthesia (including monitored anesthesia care and deep sedation) for routine upper and lower GI endoscopic procedures and specifies when anesthesia services are covered for members.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-01Cooling Devices (Passive and Active) Coverage CriteriaDefines Moda Health coverage for passive and active cooling devices used for postoperative and musculoskeletal/soft-tissue injury care, and the documentation required for prior authorization requests.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-01Zaltrap (ziv-aflibercept) — Intravenous prior authorization and coverage criteriaPrior authorization, dosing, and medical necessity criteria for intravenous ziv-aflibercept (Zaltrap) for oncology indications (primarily metastatic colorectal and appendiceal adenocarcinoma) for Moda Health providers and reviewers.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Endoscopic Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) (Transoral Incisionless Fundoplication)Defines medical necessity and coverage stance for transoral incisionless fundoplication (TIF) and other endoscopic GERD procedures for Moda Health members; specifies criteria, covered and not-covered CPT/HCPCS codes, and documentation required for prior authorization.All Moda Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-05Zevaskyn (prademagene zamikeracel) (Topical)Defines Moda Health coverage, prior authorization, dosing, and medical necessity criteria for topical Zevaskyn to treat wounds from recessive dystrophic epidermolysis bullosa (RDEB) for covered members and providers submitting PA requests.All Moda Health updates
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Tool Description
Search Moda 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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