Providence Health Plan Coverage Criteria
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Latest Providence Health Plan coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Allergy Testing (Medicare)Medicare medical policy describing coverage, medical necessity criteria parameters, and coding/billing guidance for allergy testing services for Providence Health Plan Medicare products.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Alpha-Fetoprotein (AFP) testingDefines medical necessity and coverage criteria for serum alpha-fetoprotein (AFP) testing for Providence Health Plan members, applicable primarily to commercial products and per plan benefit terms.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Artificial Intervertebral DiscsClinical coverage criteria and policy guidance for FDA‑approved cervical and lumbar artificial intervertebral disc replacement procedures for Providence Health Plan commercial members and associated product lines.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Circulating Tumor Cell and DNA Assays for Cancer ManagementMedicare medical policy governing coverage and Medicare-related guidance for circulating tumor cell (CTC) and circulating tumor DNA/cell-free DNA (ctDNA/cfDNA) assays used in cancer management for Providence Health Plan Medicare products.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Functional Electrical Stimulation (FES) for AmbulationThis policy defines medical necessity criteria, coding, and documentation requirements for use of functional electrical stimulation (FES) devices to enable walking in members, primarily addressing spinal cord injury indications and replacement devices.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Genetic Testing for Hereditary Breast, Ovarian, Pancreatic, and Prostate CancerThis policy defines medical necessity criteria, coverage limits, and non-covered genetic tests for hereditary breast, ovarian, pancreatic, and prostate cancer for Providence Health Plan commercial products and related companies.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Genetic Testing for Inherited Susceptibility to Colorectal, Endometrial and Gastric CancerPolicy governs medical necessity criteria, documentation, and coverage stance for germline genetic testing for hereditary colorectal, endometrial and gastric cancer syndromes for Providence Health Plan commercial members and affiliated product lines.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Genetic and Molecular Testing for Inherited Cancer RiskMedicare medical policy governing coverage criteria for genetic and molecular testing for inherited cancer risk for Providence Health Plan Medicare products; affects ordering providers, laboratories, and Medicare Advantage members.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Human Chorionic Gonadotropin (hCG) testingDefines medical necessity and coverage criteria for quantitative hCG testing for Providence Health Plan commercial members and related plan products; affects ordering providers and billing for laboratory hCG tests.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Minimal Residual Disease (MRD) TestingMedicare medical coverage criteria and guidance for MRD testing (solid tumor and selected hematologic indications) for Providence Health Plan Medicare products, describing test-specific and general MolDX/LCD-based requirements that affect ordering and reimbursement.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Next Generation Sequencing for CancerDefines medical necessity and coverage criteria for multi-gene/NGS tumor profiling in members with somatic cancer for Providence Health Plan commercial products. Applies to tissue-based NGS panels and excludes circulating tumor DNA/cell testing.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Planned Out-of-Hospital BirthCriteria and guidance for when planned out-of-hospital (including home) birth is considered medically appropriate or not for Providence Health Plan members across Commercial and Medicaid/OHP products.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Pneumatic Compression DevicesMedical policy governing coverage criteria for pneumatic compression devices and related accessories for Providence Health Plan commercial members; describes when devices are considered medically necessary or not.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Protein Biomarker and Genetic Testing for the ProstateThis policy describes and evaluates multiple urine-, blood-, and tissue-based protein biomarker and genetic assays used for detection, risk stratification, prognosis, and treatment decision-making in prostate cancer; it governs coverage and clinical use criteria for Providence Health Plan members and providers.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Skin and Tissue SubstitutesClinical policy governing medical necessity and coverage criteria for skin and tissue substitute products used for burns, diabetic foot ulcers, venous stasis ulcers, traumatic wounds, select reconstructive procedures, and other specified indications for Providence Health Plan commercial products.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Sleep Disorder Testing (facility-based polysomnography, MSLT/MWT)Defines medical necessity and coverage criteria for facility-based polysomnography (including split-night and full-night studies), positive airway pressure titration, multiple sleep latency/maintenance of wakefulness testing, repeat studies, and non-covered sleep testing for Providence Health Plan members.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Small Joint Surgery (Foot & Ankle) - Coverage CriteriaMedical policy governing coverage criteria for elective, non-emergent small joint surgeries of the foot and ankle for Providence Health Plan members (commercial and Medicaid/OHP products; Medicare only when directed by a separate Medicare policy).All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Transcatheter Aortic Valve Replacement (TAVR)Medical policy governing coverage criteria for transcatheter aortic valve replacement (TAVR) for Providence Health Plan product lines, affecting providers who request authorization for Commercial and Medicaid/OHP members (Medicare applicability limited).All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Tumor Antigen AssaysDefines medical necessity and coverage criteria for serum tumor antigen immunoassay testing (CA‑125, CA 15‑3/CA 27.29, CA 19‑9) for Providence Health Plan commercial members and describes coding and billing guidance.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Alpha-Fetoprotein (AFP) — Medicare Coverage Criteria (NCD 190.25)Medicare-only policy governing coverage and billing for serum alpha-fetoprotein (AFP) carcinoma testing (CPT 82105) for Providence Health Plan Medicare products and related companies.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Cochlear Implants and Auditory Brainstem ImplantsDefines medical necessity, coverage criteria, and exclusions for cochlear implants, hybrid cochlear implants, and auditory brainstem implants across Company products with notes for Commercial, Medicaid/OHP, and Medicare applicability.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Laboratory Testing ServicesThis policy defines medical necessity, documentation, and coverage criteria for laboratory tests and panels for Providence Health Plan members across commercial and Medicaid/OHP products and guides when tests are considered medically necessary or not.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Laboratory Testing ServicesDefines Medicare medical policy coverage and medical necessity criteria for laboratory and diagnostic testing services for Providence Medicare products; applies to ordering providers, laboratories, and claim reviewers.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Left Atrial Appendage Devices ClosureMedicare medical policy governing coverage and medical necessity criteria for percutaneous and non-percutaneous left atrial appendage closure procedures and devices for members of Providence Health Plan (Medicare). Affects clinicians requesting authorization or billing for LAA closure procedures and related devices.All Providence Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Percutaneous Vertebroplasty and SacroplastyMedicare medical policy governing percutaneous vertebral augmentation (vertebroplasty, kyphoplasty) and percutaneous sacral augmentation (sacroplasty) for Providence Health Plan Medicare members; describes coverage framework, definitions, background, and applicability when Medicare coverage criteria are not fully established.All Providence Health Plan updates
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Tool Description
Search Providence Health Plan 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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