Priority Health Coverage Criteria
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Latest Priority Health coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01CAROTID AND INTRACRANIAL ARTERY STENTINGThis policy governs coverage and medical necessity criteria for carotid and intracranial artery stenting procedures (including TCAR and TF‑CAS), transcatheter extracranial vertebral or intrathoracic carotid stents, and intracranial angioplasty/stenting for Priority Health members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Durable Medical EquipmentDefines coverage, medical necessity criteria, limitations, and exclusions for durable medical equipment (purchase, rental, repair, replacement, and associated supplies).All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Endoscopic Submucosal Dissection (ESD)This policy describes Priority Health coverage criteria for conventional (non-robotic) endoscopic submucosal dissection (ESD) for select gastrointestinal lesions and identifies when ESD is medically necessary, not medically necessary, or investigational. It applies to providers submitting claims to Priority Health members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01SKIN SUBSTITUTES & SOFT TISSUE GRAFTSDefines coverage criteria, limitations, and coding requirements for skin substitutes and soft tissue graft products used by Priority Health members; applies to providers submitting claims for these products.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01TRANSCATHETER CLOSURE OF SEPTAL DEFECTSThis policy governs percutaneous transcatheter closure of congenital septal defects (atrial, select non-atrial) and related coding and coverage rules for Priority Health members; coverage depends on member benefits and medical necessity criteria.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-20Employer Group Pharmacy Prior Authorization Criteria (partial)This document defines prior authorization requirements and coverage criteria for pharmacy drugs under Priority Health employer group plans; it is intended for providers submitting pharmacy prior authorization requests and for plan administrators referencing the Approved Drug List (ADL).All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01CPT Category III (Temporary 'T') Codes — Coverage and Coding GuidanceThis policy governs Priority Health's coverage stance and coding guidance for AMA CPT Category III (temporary 'T') codes used for emerging technologies, procedures, and services, and affects providers billing these codes under Priority Health plans.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01ENTERAL NUTRITIONAL THERAPYGoverns coverage and medical necessity criteria for enteral nutrition delivered via tube (nasogastric, gastrostomy, jejunostomy) including formulas, supplies, pumps, and accessory devices for Priority Health members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01EXTRACORPOREAL SHOCK WAVE THERAPY (ESWT)This policy governs medical necessity and coverage criteria for extracorporeal shock wave therapy, including ESWL and low-intensity ESWT, and specifies when therapy is medically necessary, not medically necessary, or experimental for Priority Health members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Gastroesophageal Reflux Disease (GERD) and Barrett's EsophagusDefines medical necessity criteria, coverage limitations, and investigational exclusions for diagnosis and treatment of gastroesophageal reflux disease (GERD) and Barrett's esophagus for Priority Health members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Genetics: Counseling, Testing, ScreeningCoverage criteria for genetic counseling, testing, and screening services for Priority Health members, including medical necessity, prior authorization, and services managed through eviCore. Applies to providers ordering or performing genetic services for affected members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01MODERATE SEDATION FOR INTERVENTIONAL PAIN MANAGEMENTThis policy defines when moderate (conscious) sedation or anesthesia for adults undergoing interventional pain management procedures is considered medically necessary and when it is not, and describes coding and prior authorization considerations for providers and payers.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01PERORAL ENDOSCOPIC MYOTOMY (POEM)Defines medical necessity criteria and limitations for POEM, including Z-POEM, for treatment of esophageal achalasia, Zenker's diverticulum, and select non-achalasia spastic esophageal motility disorders; applies to Priority Health members and providers.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Panniculectomy / AbdominoplastyDefines when panniculectomy is medically necessary using InterQual® criteria and states abdominoplasty is generally cosmetic unless it causes functional impairment; applies to Priority Health members for coverage determination.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Peripheral Nerve StimulationThis policy governs coverage and medical necessity criteria for transcutaneous, percutaneous, auricular, and implanted peripheral nerve stimulation devices and related electrical stimulation therapies for pain and select other indications (e.g., hyperemesis gravidarum), affecting Priority Health commercial and Medicaid members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Priority Health Medicare 2026 Formulary (Drug List) - Coverage CriteriaThis document is the 2026 formulary (drug list) for Priority Health Medicare, describing covered drugs, applicable restrictions (prior authorization, quantity limits, step therapy), member rights to exceptions and transitions, and how to use the formulary. It affects plan members, prescribers, and network pharmacies using Priority Health Medicare benefits.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Priority Health Medicare 2026 Formulary (Drug List) - Coverage CriteriaThis document is the Priority Health Medicare formulary (Drug List) that describes covered prescription drugs, coverage rules (prior authorization, step therapy, quantity limits), member rights to exceptions and transition supplies, and how to use the formulary. It affects Priority Health Medicare members, prescribers, and network pharmacies.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Priority Health Medicare Employer Group Formulary (Drug List) — Coverage CriteriaDefines the covered prescription drugs, formulary structure, restrictions (prior authorization, quantity limits, step therapy), and exception/transition processes for Priority Health Medicare Employer Group members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01RECURRENT PREGNANCY LOSSDefines medical necessity criteria for evaluation and treatment of recurrent pregnancy loss (RPL) and lists tests and therapies considered medically necessary, not medically necessary, or experimental for Priority Health members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01STEM CELL OR BONE MARROW TRANSPLANTATIONDefines medical necessity criteria, coverage scope, and facility/authorization requirements for allogeneic and autologous hematopoietic cell transplants for Priority Health members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01STEM CELL OR BONE MARROW TRANSPLANTATIONDefines medical necessity criteria, coverage, and facility/authorization requirements for allogeneic and autologous hematopoietic stem cell, bone marrow, and other blood cell transplants for Priority Health members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Sites of ServiceDefines medical necessity criteria for performing procedures in a hospital outpatient department (HOPD) instead of an ambulatory surgery center (ASC) or physician office; excludes emergency and inpatient services and does not address medical necessity for individual procedures.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01TRANSPLANTATION OF SOLID ORGANSDefines Priority Health coverage, medical necessity criteria, limitations, and authorization requirements for solid organ transplantation services (evaluation, transplant procedure, donor services, and post-transplant care) for Priority Health members.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Temporomandibular Joint (TMJ) Disorders Coverage CriteriaDefines Priority Health coverage distinctions for medical versus dental services for evaluation and treatment of temporomandibular joint disorders and lists services, coding, and applicability by product type.All priority health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Transplantation of Solid OrgansDefines Priority Health coverage, medical necessity criteria, limitations, and administrative requirements for evaluation, transplant procedures, donor services, and post‑transplant care for solid organ transplants.All priority health updates
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Tool Description
Search Priority 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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