Oscar Health Coverage Criteria
Latest Oscar Health coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01B-Hemolytic Streptococcus TestingDefines coverage criteria, indications, and limitations for laboratory testing to detect beta-hemolytic streptococcal infections (including Groups A, B, C, G) for Oscar Health members and guidance for providers on claims and documentation.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Biochemical Markers of Alzheimer Disease and DementiaDefines coverage criteria for biochemical (blood, plasma, CSF, urine, and other media) biomarkers used to aid diagnosis or evaluation of Alzheimer disease and other dementias for Oscar Health members.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Biomarker Testing for Multiple Sclerosis and Related Neurologic DiseasesDefines coverage criteria and limitations for cerebrospinal fluid and serum biomarker testing used to diagnose or evaluate multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), and MOG-IgG–associated disease; intended for providers submitting claims to Oscar Health.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Cardiovascular Disease Risk AssessmentDefines coverage, frequency, and limitations for laboratory testing and biomarkers used to assess cardiovascular disease (CVD) risk for Oscar Health members, and indicates who and when testing is covered.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Celiac Disease TestingDefines medically necessary and non-covered laboratory and diagnostic testing for diagnosis and monitoring of celiac disease for Oscar Health members; applies to providers submitting claims for relevant serologic, genetic, biopsy, and point-of-care tests.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Cervical Cancer ScreeningDefines coverage criteria and limits for cervical cancer screening (Pap cytology, high-risk HPV testing, and co-testing) for individuals with a cervix, including special populations such as immunocompromised individuals and those with prior abnormal results.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Colorectal Cancer ScreeningDefines Oscar Health's coverage stance, indications, and limits for colorectal cancer screening modalities (stool-based tests, blood/plasma tests, and related proprietary assays) for members, including age-based recommendations and tests considered not covered.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Diabetes Mellitus Testing — Coverage CriteriaDefines coverage criteria and limitations for laboratory testing used to screen, diagnose, and monitor diabetes mellitus and prediabetes for Oscar Health members.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Diagnostic Testing Of Iron Homeostasis & MetabolismDefines coverage criteria and limitations for laboratory testing of iron status (e.g., ferritin, transferrin saturation) for Oscar Health members; applies to providers submitting claims for these tests. Coverage is dependent on member benefits and applicable state/federal rules.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Evaluation of Dry EyesDefines coverage and clinical guidance for diagnostic testing used to evaluate dry eye disease (DED), specifying which tear biomarkers and osmolarity tests meet or do not meet coverage criteria for Oscar Health members.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Folate Testing — Coverage CriteriaDefines coverage and limitations for serum, red blood cell (RBC), urinary, and folate receptor autoantibody testing for folate (vitamin B9) for Oscar Health members. Applies to providers submitting claims to Oscar and governs medical necessity and reimbursement guidance.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Gamma-glutamyl Transferase (GGT) Testing in AdultsCriteria for coverage and reimbursement of serum GGT testing in individuals 18 years and older, including indications, frequency limits, and limitations for Oscar Health members and providers submitting claims.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01General Inflammation Testing (CRP and ESR) Coverage CriteriaThis policy governs coverage and reimbursement for C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) testing for inflammatory conditions for Oscar Health members. It describes covered indications, test preferences, and limitations applicable to providers submitting claims.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Hepatitis Testing (A, B, C, D) Coverage CriteriaDefines medical necessity and coverage criteria for laboratory testing for hepatitis A, B, C, and D for insured members, including screening, diagnostic, and monitoring indications and test-specific coverage statements.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Human Immunodeficiency Virus (HIV) — Coverage Criteria for Testing and Resistance AssaysDefines coverage and medical necessity criteria for HIV screening, diagnostic testing, viral load monitoring, genotypic and phenotypic resistance testing, and limits for repeat testing; applies to providers submitting claims to Oscar Health.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Immune Cell Function AssayDefines Oscar Health's coverage stance and clinical background for immune cell function assays (e.g., ImmuKnow, Pleximmune, iQue) and describes indications, limitations, and supporting evidence relevant to diagnosis and management primarily in transplant and primary immunodeficiency contexts.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Laboratory Testing for the Diagnosis of Inflammatory Bowel DiseaseDefines coverage and limitations for fecal and serologic laboratory tests used to diagnose and monitor inflammatory bowel disease (IBD) for Oscar Health members, and describes which tests meet or do not meet coverage criteria.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Lyme Disease Testing Coverage CriteriaDefines coverage, indications, limitations, and acceptable testing methodologies for laboratory diagnosis of Lyme disease for Oscar Health members.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Nerve Fiber Density Testing (IENFD/ENFD) Coverage CriteriaDefines coverage criteria, limitations, and clinical background for epidermal nerve fiber density testing (skin biopsy) to evaluate small-fiber neuropathy for Oscar Health members.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Pancreatic Enzyme Testing for Acute PancreatitisThis policy governs coverage and reimbursement for laboratory measurement of pancreatic enzymes (lipase, amylase, trypsinogen/TAP, and selected inflammatory biomarkers) for diagnosis and management of acute pancreatitis for Oscar Health members and providers submitting claims to Oscar.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Pathogen Panel TestingRules for outpatient pathogen panel diagnostic testing (multiplex PCR and antigen panels) including indications, limitations, and which panels meet or do not meet coverage criteria for Oscar Health members.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Prostate Specific Antigen (PSA) TestingDefines clinical coverage criteria, indications, limitations, and guideline context for total PSA and related PSA-based tests for prostate cancer screening, diagnosis, monitoring, and follow-up for Oscar Health members.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01RTM Testing for Alpha-1 Antitrypsin DeficiencyDefines medical necessity and coverage criteria for laboratory testing to diagnose alpha-1 antitrypsin deficiency (AATD), including serum AAT quantification, phenotyping/proteotyping, isoelectric focusing, and genotyping; applies to providers submitting claims to Oscar Health.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Serum Testing For Evidence of Mild Traumatic Brain InjuryDefines Oscar Health's coverage stance for serum (and other fluid) biomarker tests used to evaluate mild traumatic brain injury (mTBI)/concussion for members; applies to providers submitting claims under Oscar reimbursement rules.All Oscar Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Testosterone — Coverage Criteria for Measurement and MonitoringCriteria for coverage and limitations for measurement of testosterone and related hormones for diagnosis and monitoring across sexes and gender-diverse persons; applies to providers submitting claims to Oscar Health.All Oscar Health updates
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Tool Description
Search Oscar 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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