Premerabluecrossofwashington Coverage Criteria
Latest Premerabluecrossofwashington coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2027-02-05Mohs Micrographic SurgeryThis policy governs when Mohs micrographic surgery may be considered medically necessary for skin cancers and other cutaneous malignancies or lesions, including documentation and coding requirements for providers.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2027-02-05Optilume Drug-Coated Balloon Treatment for Urethral Stricture and BPHThis policy addresses coverage of the Optilume urethral drug-coated balloon for recurrent bulbar urethral stricture in adult men and classifies other urethral uses and the Optilume BPH Catheter System as investigational.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2027-02-05Optilume Urethral Drug-Coated Balloon for Recurrent Urethral StrictureThis policy addresses medical necessity and investigational status for the Optilume urethral drug-coated balloon in adult men with recurrent anterior urethral stricture and the Optilume BPH Catheter System for lower urinary tract symptoms secondary to benign prostatic hyperplasia. It also specifies documentation and billing codes for provider review.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2027-02-05Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial FibrillationThis policy governs medical necessity and documentation requirements for percutaneous left atrial appendage closure or occlusion devices used to prevent stroke in individuals with non-valvular atrial fibrillation. FDA-approved devices may be covered when specified stroke, anticoagulation, contraindication, and bleeding-risk criteria are met; other devices are considered investigational.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2027-01-01Medical Necessity Criteria for Drugs Subject to Site of Service ReviewThis policy establishes medical-necessity, step-therapy, site-of-service, authorization, and documentation requirements for intravenous, injectable, and selected oral drugs used to treat active psoriatic arthritis. Site-of-service review applies to members age 13 and older, except Alaska fully insured members.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-16Psychiatric and Other Specified Evaluations for Behavioral Health TreatmentThis policy supplements InterQual medical-necessity criteria by specifying evaluation types, timing, and eligible clinician types for inpatient, residential, and partial hospital behavioral health treatment, including mental health, substance use disorder, withdrawal management, eating disorder, and PHP services.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-16Psychiatric and Specified Evaluations in Behavioral Health TreatmentThis policy supplements InterQual medical-necessity criteria by specifying provider types, timing, frequency, and distinct documentation requirements for psychiatric, medical, substance use, and nutritional evaluations during inpatient, residential, withdrawal-management, and partial hospital behavioral health treatment.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-06Endovascular Stent Grafts for Abdominal Aortic AneurysmsThis policy governs when endovascular aneurysm repair using FDA-approved endoprostheses for infrarenal abdominal aortic or aorto-iliac aneurysms may be medically necessary and covered. It also identifies an investigational bifurcated-bifurcated repair technique, required clinical documentation, applicable procedure codes, and post-implantation imaging information.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-06Endovascular Stent Grafts for Abdominal Aortic AneurysmsThis policy governs when endovascular aneurysm repair using endoprostheses for infrarenal abdominal aortic or aorto-iliac aneurysms may be medically necessary and what documentation is required. It also identifies bifurcated-bifurcated endoprosthesis repair as investigational.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-06Endovascular Stent Grafts for Abdominal Aortic AneurysmsThis policy governs when endovascular aneurysm repair using FDA-approved endoprostheses may be medically necessary for infrarenal abdominal aortic or aorto-iliac aneurysms, including standard, fenestrated, and branched devices. It also identifies an investigational bifurcated-bifurcated repair and specifies documentation and coding information for providers.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01BCL-2 InhibitorsThis policy governs pharmacy-benefit coverage and prior authorization for Beqalzi (sonrotoclax) and Venclexta (venetoclax), including medically necessary uses, clinical criteria, documentation, dosing limits, authorization durations, and investigational uses for specified hematologic malignancies.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Behavioral Health: Residential/Sub-Acute Withdrawal Management (Detoxification)This policy governs when residential or sub-acute withdrawal management (detoxification) for substance use disorders may be medically necessary in qualifying residential, hospital-based, psychiatric residential, or stand-alone withdrawal management facilities.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Chronic Hepatitis B and D Antiviral TherapyThis policy governs medical-necessity criteria, documentation, authorization duration, and benefit administration for Baraclude, Hepcludex, and Vemlidy used to treat chronic hepatitis B or D infection. It is intended for providers submitting requests for these pharmacy-benefit medications.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Gender-Affirming Surgery and Related ServicesCoverage criteria and medical-necessity review for gender transition/affirmation surgeries, modifications to prior surgery, hair removal, medical tattooing, fertility preservation, and related services. Coverage depends on the member contract and applies to feminization, masculinization, and non-binary transition services.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Peginterferon alfa-2aThis policy governs pharmacy-benefit coverage of Pegasys (peginterferon alfa-2a) for specified chronic viral infections, essential thrombocytopenia, and myelofibrosis. Coverage depends on meeting condition-specific medical necessity criteria and submitting supporting clinical documentation.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial FibrillationThis policy governs medical necessity and coverage of percutaneous left atrial appendage closure devices for stroke prevention in individuals with atrial fibrillation. FDA-approved devices may be medically necessary when stroke risk warrants systemic anticoagulation but the long-term risks of anticoagulation outweigh the risks of device implantation; other devices are investigational.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Selective Estrogen Receptor Modulators and Down RegulatorsCoverage criteria, documentation requirements, coding information, evidence review, references, and history for selective estrogen receptor modulators and down-regulators used in breast cancer treatment and risk reduction.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Small Bowel TransplantationThis policy addresses when isolated small bowel, living-donor small bowel, and small bowel retransplantation may be considered medically necessary for adult and pediatric individuals, including documentation, coding, contraindications, and facility requirements.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Cryoablation of Tumors Located in the Kidney, LungThis policy describes when cryosurgical ablation of selected kidney and lung tumors is medically necessary, investigational, or not covered. Pediatric indications are not addressed.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or BoneCoverage criteria for cryosurgical ablation of tumors in the kidney, lung, breast, pancreas, or bone, including medically necessary and investigational indications; pediatric indications are not addressed.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01HIV/AIDS Pharmacologic Prevention and TreatmentCoverage criteria for brand-name HIV medications, specifically Truvada, for HIV pre-exposure prophylaxis or treatment under the pharmacy benefit.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Radioembolization for Liver MalignanciesThis policy governs when intra-arterial radioembolization may be considered medically necessary for primary and metastatic liver cancers. It applies to providers submitting requests for coverage and specifies documentation, coding, and investigational-use limitations.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Radioembolization for Primary and Metastatic Liver TumorsThis policy governs when intra-arterial radioembolization may be considered medically necessary for primary liver cancers and selected hepatic metastases. It applies to providers submitting coverage requests and defines documentation and coding requirements.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Radioembolization for Primary and Metastatic Liver TumorsThis policy governs when hepatic radioembolization may be medically necessary for primary liver cancers and selected liver metastases, and identifies other indications as investigational. It also specifies supporting documentation and applicable procedure and supply codes for providers.All premerabluecrossofwashington updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Remote Electrical Neuromodulation for MigrainesThis policy governs coverage of remote electrical neuromodulation (REN), such as Nerivio, for migraine prevention and continuation of treatment. It defines medical-necessity criteria, investigational uses, coding, contraindications, and documentation expectations for providers.All premerabluecrossofwashington updates
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Search Premerabluecrossofwashington 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.
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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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