Moda_health_plan_inc Coverage Criteria
Latest Moda_health_plan_inc coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-13Ankle-Foot (AFO)/Knee-Ankle-Foot (KAFO)/Hip-Knee-Ankle-Foot (HKAFO) Orthoses (Custom fabricated)Defines medical necessity, prior authorization requirements, covered and non-covered indications, and coding for custom-fabricated ankle-foot, knee-ankle-foot, and hip-knee-ankle-foot orthoses for Moda Health members.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-13Cranial Orthotics (Cranial bands and helmets)Defines coverage criteria, required documentation, and applicable billing codes for cranial orthotic devices (bands and helmets) for infants, and who is eligible under Moda Health Plan Inc.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-13Endoscopic Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) (Transoral Incisionless Fundoplication)Defines medical necessity, coding, and coverage stance for endoscopic and related minimally invasive procedures to treat GERD for Moda Health Plan members and specifies which procedures are considered medically necessary versus experimental/investigational.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-13Negative Pressure Wound Therapy (NPWT) (Vacuum-Assisted Wound Closure)Medical necessity and coverage policy for negative pressure wound therapy (vacuum-assisted wound closure) including indications, coverage criteria, coding, and prior authorization documentation requirements for Moda Health Plan Inc members.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-13Panniculectomy (Abdominal skin/fat surgery)This policy defines medical necessity criteria, documentation, and coding for panniculectomy (surgical excision of an abdominal apron/pannus) and explains which related procedures are considered cosmetic and not covered. It applies to Moda Health Plan Inc members and providers requesting prior authorization for panniculectomy.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-13Push-Rim Activated Power-Assist Device (E0986) — Manual Wheelchair AccessoryCoverage policy for push-rim activated power-assist devices (HCPCS E0986) used to convert manual wheelchairs for Moda Health members, defining medical necessity criteria, documentation and prior authorization requirements that affect suppliers and clinicians ordering the device.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-13Upper Extremities Custom Orthoses (Shoulder, elbow, wrist, hand, finger)This policy defines medical necessity, coverage criteria, required documentation, and billing codes for custom orthotic devices applied to the shoulder, elbow, wrist, hand, and fingers for Moda Health Plan members.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Genetic Testing — Medical Necessity and Coverage CriteriaDefines medical necessity, coverage criteria, required documentation, and applicable CPT/HCPCS codes for genetic and molecular testing services for Moda Health members.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Continuous Glucose Monitoring (CGM)Defines medical necessity, coverage criteria, prior authorization information, and covered CPT/HCPCS codes for FDA‑approved continuous glucose monitoring systems and related supplies for Moda Health Plan members.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Mobile Outpatient Cardiac Telemetry (MOCT)Policy governs medical necessity and coverage criteria for Mobile Outpatient Cardiac Telemetry (MOCT/MCT) for members of Moda Health Plan Inc., including required documentation and applicable CPT/ICD-10 codes.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Portrazza (necitumumab) (Intravenous) Coverage CriteriaDefines prior authorization, dosing, coverage criteria, and billing for necitumumab (Portrazza) used for first-line treatment of metastatic squamous non-small cell lung cancer in adult patients.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-05Zevaskyn (prademagene zamikeracel) topical therapy coveragePolicy governing prior authorization, dosing, billing, and medical necessity criteria for Zevaskyn topical autologous cellular sheets for treatment of recessive dystrophic epidermolysis bullosa (RDEB) for Moda Health Plan members.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-05Vyjuvek (beremagene geperpavec-svdt) topical policyDefines prior authorization, dosing limits, coverage criteria, renewal rules, billing codes, and documentation requirements for Vyjuvek topical therapy for dystrophic epidermolysis bullosa (DEB) for Moda Health Plan members.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-03Tzield (teplizumab-mzwv) (Intravenous) — Coverage Criteria for Stage 2 and Stage 3 Type 1 DiabetesPolicy governing prior authorization, dosing, administration, and renewal criteria for Tzield (teplizumab-mzwv) for Stage 2 and Stage 3 type 1 diabetes patients under Moda Health Plan Inc.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-08-30Sustol® (granisetron extended-release) (Subcutaneous) — Prior Authorization and Coverage CriteriaDefines prior authorization, dosing limits, clinical criteria, billing codes, and coverage conditions for Sustol (granisetron extended-release) administered subcutaneously for prevention of chemotherapy-induced nausea and vomiting (CINV) for Moda Health Plan members.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyAtezolizumab (Tecentriq) — Intravenous therapy coverageDefines prior authorization, dosing limits, and medical necessity criteria for intravenous atezolizumab (Tecentriq) across multiple cancer indications for Moda Health Plan members and providers requesting coverage.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyAvlayah (tividenofusp alfa-eknm) coverage for Hunter syndrome (MPS II)Defines prior authorization, dosing, coverage criteria, and billing/coding for Avlayah (tividenofusp alfa-eknm) for treatment of Hunter syndrome (MPS II) for eligible members.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyCabazitaxel (Jevtana®) intravenous therapy - Coverage CriteriaCoverage and medical necessity criteria for intravenous cabazitaxel (Jevtana® and other cabazitaxel products) for use primarily in metastatic castration‑resistant prostate cancer and related indications; applies to Moda Health Plan Inc provider authorization and pharmacy/infusion billing. Affects providers requesting authorization for cabazitaxel.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyHerceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Subcutaneous) coverage criteriaDefines prior authorization, dosing, authorization length, and medical necessity criteria for Herceptin Hylecta (subcutaneous) for adults with HER2-positive breast cancer for Moda Health Plan providers and reviewers.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyKresladi (marnetegragene autotemcel) (Intravenous) — Coverage CriteriaDefines prior authorization, dosing, eligibility, and monitoring requirements for coverage of Kresladi (marnetegragene autotemcel) for treatment of severe Leukocyte Adhesion Deficiency-I (LAD‑I) under Moda Health Plan Inc.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyPedmark (sodium thiosulfate) (Intravenous) coverage for cisplatin ototoxicity prevention in pediatricsDefines prior authorization, dosing limits, and medical necessity criteria for intravenous Pedmark (sodium thiosulfate) to reduce cisplatin-induced ototoxicity, primarily for pediatric members receiving cisplatin. Applies to coverage and utilization management by Moda Health Plan Inc.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyPhesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf) — subcutaneousDefines prior authorization, dosing, administration, and medical necessity criteria for use of Phesgo (subcutaneous pertuzumab/trastuzumab/hyaluronidase) for HER2-positive breast cancer for Moda Health Plan members and providers submitting authorization requests.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyQalsody (tofersen) (Intrathecal) — Coverage CriteriaDefines prior authorization, dosing, coding, and medical necessity criteria for intrathecal Qalsody (tofersen) for members with SOD1‑mutation amyotrophic lateral sclerosis (ALS) and who meet specified clinical measures. Applies to Moda Health Plan Inc coverage determinations.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyTecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) — Subcutaneous coverage criteriaDefines prior authorization, dosing limits, and medical necessity criteria for coverage of Tecentriq Hybreza (subcutaneous atezolizumab and hyaluronidase-tqjs) across multiple oncology indications for Moda Health Plan Inc.All moda_health_plan_inc updates
- Coverage CriteriaClinical/Medical PolicyTrabectedin (Evdi; Yondelis) — Intravenous therapy coverage criteriaDefines prior authorization, dosing, indications, and renewal criteria for intravenous trabectedin (Yondelis/Evdi) for members receiving care under Moda Health Plan Inc. Applies to providers requesting coverage for trabectedin infusions.All moda_health_plan_inc updates
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Tool Description
Search Moda_health_plan_inc 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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