Northwood Coverage Criteria
Latest Northwood coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-11Prefabricated and Custom Knee Orthoses (L18xx range) — Coverage Criteria and Coding GuidanceDefines medical necessity, coverage, and billing relationships for prefabricated and custom knee orthoses (various L-codes) for ambulatory members and specifies when additions are separately payable or denied. Affects providers supplying knee orthoses and payers processing claims.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-30Powered exoskeleton orthosis (DMEPOS) coverage criteriaDefines Northwood coverage stance and HCPCS coding for powered lower‑extremity exoskeleton orthoses used to enable ambulation for individuals with spinal cord injury and other lower‑limb impairments; applies to benefit determinations for DMEPOS items under Northwood's plans.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-20Non-Implantable Pelvic Floor Electrical StimulatorPolicy governs coverage and medical necessity determinations for non-implantable pelvic floor electrical and magnetic stimulation devices for treatment of urinary incontinence, overactive bladder, and fecal incontinence for Northwood plan members.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-05-11Continuous Passive Motion (CPM) Devices — Coverage CriteriaThis policy defines coverage, limitations, and billing/documentation requirements for continuous passive motion devices used as an adjunct to physical therapy for joint rehabilitation, with separate rules for Medicare and non‑Medicare members.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-03-11Personal Emergency Response System (PERS) — DMEPOS Coverage CriteriaThis policy defines medical necessity, device/vendor standards, documentation, and coverage requirements for in-home Personal Emergency Response Systems (PERS) provided as DMEPOS for Northwood members.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Respiratory Assist Device (RAD) coverage — E0470 / E0471Defines coverage, medical necessity criteria, and documentation requirements for RADs (E0470, E0471) for Northwood members, including indications such as restrictive thoracic disorders, severe COPD, central or complex sleep apnea, hypoventilation syndromes, and chronic respiratory failure due to COPD. Affects treating practitioners, suppliers, and prior authorization processes.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Automatic External Defibrillator (AED) coverageDefines coverage criteria, limitations, and supporting diagnosis codes for automatic external defibrillators (wearable and non-wearable) for Northwood members; affects ordering practitioners and members meeting medical necessity criteria.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Orthopedic Footwear and Foot OrthoticsCriteria, coding, and coverage stance for orthopedic footwear, foot orthotics, shoe modifications, and related supplies for Northwood members; governs medical necessity determinations for adults and children and coding/billing requirements.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-02-01Eye prosthesis (ocular prosthesis and related scleral devices)Governs coverage and medical necessity criteria for eye prostheses and related services (e.g., polishing, enlargement, reduction, scleral cover shells, ocular conformers) for Northwood members across Medicare, Commercial, and NH Medicaid lines where applicable.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-01Manual Wheelchair Bases (Coverage Criteria)Defines medical necessity, coverage criteria, and coding guidance for manual wheelchair bases and related accessories for members requiring mobility assistance in the home; applies to providers and suppliers submitting claims to Northwood.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-01Transcutaneous Electrical Nerve Stimulators (TENS)Coverage and medical necessity criteria for TENS devices and related supplies for treatment of acute post-operative pain, chronic intractable pain, and chronic low back pain for Northwood members.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-12-07Wheelchair cushions and seating systems — Coverage CriteriaThis policy governs coverage and medical necessity criteria for wheelchair seat and back cushions, seating systems, and related mounting hardware for Members who use manual or power wheelchairs; it specifies covered HCPCS codes, clinical criteria, and billing rules.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-24Facial prosthesis — Coverage criteria, coding, documentation, and limitationsGoverns coverage, coding, documentation, and limitations for facial prostheses and related supplies for Northwood members; applies to both Medicare (with cross-reference) and non‑Medicare members as described.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-01Airway Clearance DevicesDefines medical necessity, coverage criteria, limitations, and coding for airway clearance devices (PEP, oscillating PEP, postural drainage board, percussor) for members with excessive respiratory secretions and impaired airway clearance. Affects treating practitioners, DME suppliers, and members receiving durable medical equipment services.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-05-01Pressure Reducing Support Surfaces - Group 3 (Air-fluidized bed)This policy governs coverage and medical necessity criteria for air-fluidized beds (HCPCS E0194) used to treat stage 3–4 pressure ulcers and specifies documentation, denial reasons, and monthly recertification requirements for members receiving the device.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-03-15Insulin Infusion Pump and Supplies Coverage CriteriaClinical policy governing medical necessity and coverage of external insulin infusion pumps and associated supplies for members with diabetes mellitus or other conditions causing insulinopenia; applies to providers ordering and managing pump therapy under Northwood plans.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Home pulse oximeter (pulse oximetry) for outpatient/home useDefines Northwood coverage and medical necessity criteria for home pulse oximeters and replacement probes for Medicare and non‑Medicare members, with special pediatric indications and exclusions.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Tracheostomy care supplies — coverage criteria and DME medical necessityThis policy governs coverage and medical necessity criteria for tracheostomy care kits and related supplies for members following an open surgical tracheostomy, including quantity limits and coding guidance. It affects providers ordering or billing for tracheostomy supplies under Northwood plans.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-06-20Commode and Raised Toilet Seat Coverage (DME)Policy governs coverage and medical necessity criteria for commode chairs and raised toilet seats (DME) for Northwood members; includes Medicare-reference and additional non-Medicare criteria and HCPCS codes. Affects providers ordering and billing these DME items.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-06-01Oxygen and Oxygen Equipment (Medicaid) - Coverage CriteriaCoverage rules for oxygen therapy and oxygen delivery equipment (stationary, portable, ambulatory, and concentrators) for Medicaid members, including adult and pediatric criteria, qualifying lab values, reassessment, and short-term use guidance.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Home phototherapy (Bilirubin light / Bili-blanket) coverage criteriaGoverns coverage and medical necessity criteria for home phototherapy devices for newborns with hyperbilirubinemia; applies to infants >=35 weeks gestation and their treating practitioners requesting home phototherapy equipment and services.All northwood updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Mechanical Stretch Devices for Contractures and Joint StiffnessDefines medical necessity, coverage criteria, limitations, and exclusions for mechanical stretching devices (LLPS and SP) used to treat joint stiffness or contractures for Northwood members.All northwood updates
- Coverage CriteriaClinical/Medical PolicyAerochamber: Drug Delivery Systems for Metered Dose Inhaler (MDI)Defines coverage, limitations, and documentation requirements for drug delivery systems (spacers/holding chambers/reservoir bags) used with metered dose inhalers for Northwood members; distinguishes Medicare and non‑Medicare handling and applies to DMEPOS benefit determinations.All northwood updates
- Coverage CriteriaClinical/Medical PolicyAir cleaner / purifier (DME) coverage criteriaDefines Northwood's coverage stance for air cleaners/purifiers (environmental control equipment) and the applicable HCPCS code, for members and providers seeking DME benefits.All northwood updates
- Coverage CriteriaClinical/Medical PolicyAir-fluidized bed (Pressure reducing support surface - Group 3) coverage and medical necessityCoverage and medical necessity criteria for air-fluidized beds (HCPCS E0194) as a Group 3 pressure reducing support surface for members requiring DME; governs supplier and treating practitioner documentation, coverage limitations, and contraindications.All northwood updates
1–25 of 118
1 / 5
Tool Description
Search Northwood 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.
Coverage Criteria by Payer
Go deeper
Explore OpenPayer Data
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.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Prior Authorization LookupSearch payer prior authorization policies by drug, procedure, or policy name.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.