Priority_health_medicare Coverage Criteria
Latest Priority_health_medicare coverage criteria updates15
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01HyperhidrosisThis policy addresses medical necessity and coding for treatments of hyperhidrosis, including coverage criteria for intractable, disabling primary hyperhidrosis and exclusions for unproven or noncovered treatments.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Medically Supervised Withdrawal Management (Detoxification)This policy governs coverage and medical necessity for acute inpatient medical and psychological care to manage acute withdrawal from alcohol or other substances. General substance use disorder treatment is outside the policy scope, and coverage remains subject to the member’s specific benefits and applicable plan documents.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Septoplasty / RhinoplastyThis policy governs when septoplasty and rhinoplasty may be considered medically necessary, including clinical criteria, documentation requirements, prior authorization, coding, exclusions, and experimental or unproven procedures.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Moderate Sedation for Interventional Pain ManagementThis policy governs when moderate (conscious) sedation or anesthesia is medically necessary for adults undergoing interventional pain management procedures, subject to the member's specific benefits and applicable mandates.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyCategory III Current Procedural Terminology (CPT) CodesThis policy governs Priority Health Medicare coverage of temporary CPT Category III (“T”) codes used for emerging technologies, services, procedures, and service paradigms. Unless another Priority Health or utilization-management delegate policy or guideline provides medical-necessity criteria, services represented by these codes are considered experimental, investigational, or unproven.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyChelation TherapyThis policy establishes medical necessity and coverage criteria for chelation therapy, including covered diagnoses and supporting diagnosis codes. It applies to Priority Health Medicare members, subject to specific benefits and applicable federal or state mandates.All priority_health_medicare updates
- Coverage CriteriaReimbursement/Payment PolicyCosmetic and Reconstructive SurgeryThis policy governs billing, coding, documentation, medical necessity, and reimbursement for cosmetic and reconstructive surgery services for Priority Health Medicare. Cosmetic procedures performed solely to improve appearance are generally not reimbursable, while reconstructive procedures may be reimbursed when medically necessary to restore function or correct abnormalities.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyHistotripsy for Malignant Liver TumorsThis policy governs coverage of histotripsy, including the Edison Histotripsy System, for malignant liver tumors in Priority Health Medicare members. Coverage is limited to medically necessary treatment meeting the specified tumor size, age, and multidisciplinary-treatment criteria.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyHyperbaric Oxygen TherapyThis policy establishes medical necessity criteria for systemic hyperbaric oxygen therapy for selected wound-related and non-wound indications, and identifies topical hyperbaric oxygen therapy and home hyperbaric oxygen chambers as excluded or not medically necessary.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyIntravascular LithotripsyThis policy governs coverage of intravascular lithotripsy for endovascular revascularization of lower-extremity and coronary arteries. Lower-extremity use is medically necessary only when specified lesion, runoff, calcium, and vessel criteria are met; coronary use is experimental and investigational.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyNeuropsychological and Psychological TestingThis policy governs medical necessity and coverage criteria for neuropsychological and psychological testing, including applicable exclusions and billing codes. It applies to Priority Health products subject to the member’s specific benefit plan and, for Medicare members, CMS coverage determinations.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyPrior Authorization Criteria for Specialty DrugsThis document lists Priority Health Medicare Dual Premier prior authorization requirements for covered prescription drugs, including required documentation, clinical criteria, exclusions, prescriber restrictions, prerequisite therapy, and coverage duration. It applies to members of the 2026 Priority Medicare Dual Premier HMO D-SNP.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyTonic Motor Activation (ToMAc) Peroneal Nerve Stimulation for Restless Leg Syndrome (i.e., Nidra™) – Medicare AdvantageThis Medicare-only medical policy governs coverage consideration for tonic motor activation (ToMAc) peroneal nerve stimulation, including Nidra™, for adults with medication-refractory restless legs syndrome. Coverage is subject to the member's plan benefits and requires satisfaction of all stated medical necessity criteria.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyVaricose Vein TreatmentThis policy governs coverage of lower-extremity varicose vein treatment, including ablation, sclerotherapy, phlebectomy, ligation and division, and subfascial endoscopic perforator surgery, subject to InterQual criteria, member benefits, and applicable CMS requirements.All priority_health_medicare updates
- Coverage CriteriaClinical/Medical PolicyVentricular Assist Devices & Artificial HeartsCoverage criteria and medical necessity requirements for ventricular assist devices, percutaneous right ventricular assist devices, total artificial hearts, and related remote vital-sign monitoring.All priority_health_medicare updates
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Tool Description
Search Priority_health_medicare 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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