Regence Coverage Criteria
Latest Regence coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-12-01RhinoplastyThis policy governs coverage of initial or revision rhinoplasty and excision or shaving of rhinophyma. Rhinoplasty is generally cosmetic, but may be covered as medically necessary for specified congenital, post-tumor, traumatic, or functional nasal airway conditions when documentation and clinical criteria are met.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Applied Behavior Analysis for the Treatment of Autism Spectrum DisorderThis policy governs medical necessity, authorization, documentation, provider qualifications, and coverage criteria for ABA assessment and treatment of members with autism spectrum disorder. It applies to member contracts subject to ABA preauthorization and applicable state autism or mental health parity benefits.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Autologous Chondrocyte Implantation for Focal Articular Cartilage LesionsThis policy governs coverage of autologous chondrocyte implantation (ACI), including MACI, for focal full-thickness articular cartilage defects. It applies to provider requests for treatment of disabling knee cartilage lesions and identifies when the procedure is medically necessary versus investigational.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty)Coverage of intervertebral disc decompression using laser or radiofrequency energy, including laser discectomy, disc nucleoplasty, and related adjunctive chemonucleolysis.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Dental and Orthodontic Treatment for Craniofacial AnomaliesThis policy guides medical-necessity determinations for dental and orthodontic services used to treat congenital craniofacial anomalies when treatment is needed to restore function. It applies to providers and members subject to applicable contract terms; contract language takes precedence.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-11-01Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital SitesCoverage review for SRS and SBRT/SABR used to treat neoplastic and non-neoplastic conditions at intracranial, skull base, and orbital sites, with clinical documentation required to support medical necessity.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted TherapyThis policy governs coverage of tumor-tissue testing for BRAF variants when used to select targeted therapy for individuals with advanced, metastatic, or unresectable melanoma or with glioma. It also identifies investigational uses and the documentation required for medical-necessity review.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Charged-Particle (Proton) RadiotherapyThis policy governs medical-necessity evaluation and documentation requirements for charged-particle irradiation, primarily proton beam therapy, for definitive, adjuvant, or salvage treatment of primary or metastatic tumors.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Evaluating the Utility of Genetic PanelsThis policy governs evaluation of the clinical utility of genetic panel tests, including panels used for hereditary cancer risk assessment, pharmacogenetics, and diagnosis of congenital disorders. It applies to providers requesting coverage for genetic panel testing under applicable contract terms.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Extracranial Carotid Angioplasty and Stenting and Embolic Protection DevicesThis policy governs coverage of extracranial carotid angioplasty, carotid artery stenting, and embolic protection devices for carotid artery dissection and carotid stenosis. It specifies when these services may be medically necessary, when they are investigational, and the information providers must submit for review.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Femoroacetabular Impingement SurgeryCoverage of open or arthroscopic femoroacetabular impingement surgery in skeletally mature patients when clinical, examination, imaging, and treatment-history criteria support medical necessity.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Low-Level Laser TherapyThis policy governs coverage of low-level laser therapy, also called photobiomodulation, including its use for preventing oral mucositis during cancer treatment. Coverage applies when the device is FDA-approved and the treatment is requested for individuals at increased risk of oral mucositis from chemotherapy, radiotherapy, or hematopoietic cell transplantation.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Reconstructive Breast Surgery/Mastopexy, and Management of Breast ImplantsThis policy governs coverage criteria, documentation, and coding for breast reconstruction, symmetry procedures, mastopexy, breast implant explantation or replacement, and related prostheses, subject to applicable contract terms and exclusions.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Chemical PeelsThis policy governs coverage of epidermal and dermal chemical peels, including the clinical circumstances in which they may be medically necessary, not medically necessary, or cosmetic. It applies to providers submitting chemical peel services under Regence BlueCross BlueShield benefits, subject to applicable contract terms.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Genetic Testing for PTEN Hamartoma Tumor SyndromeThis policy governs coverage of genetic testing for PTEN variants used to evaluate PTEN hamartoma tumor syndrome. Testing is medically necessary only when specified family-history or clinical criteria are met and required clinical documentation is submitted.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Investigational Gene Expression, Biomarker, and Multianalyte TestingThis policy governs coverage of gene expression, biomarker, and multianalyte assays used for diagnosis, prognosis, risk assessment, treatment selection, or disease monitoring. The listed tests are considered investigational because current evidence is insufficient to demonstrate improved health outcomes.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Single-nucleotide Variants (SNVs) to Predict Risk of Nonfamilial Breast CancerThis policy governs coverage of commercially available tests that combine single-nucleotide variants to estimate an individual's risk of nonfamilial breast cancer. Testing for SNVs and named SNV-based breast cancer risk assays is considered investigational for all indications.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Vertical Expandable Prosthetic Titanium RibCoverage of VEPTR use, including expansion, for infants and children with progressive thoracic insufficiency syndrome caused by rib or chest wall defects; other indications, including scoliosis without thoracic insufficiency, are investigational.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Patient Lifts and Seat LiftsThis policy governs coverage and medical necessity review for patient lifts, multi-positional transfer systems, and seat lift devices for members whose mobility and transfer needs meet specified criteria. It applies only to certain member contracts, and contract language takes precedence over the policy.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Vagus Nerve StimulationThis policy governs coverage and medical necessity for implantable and non-implantable vagus nerve stimulation, including initial treatment, revisions, and device or generator replacement. It applies to providers seeking coverage for VNS services, with clinical documentation required for review.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Wireless Capsule Endoscopy for Gastrointestinal (GI) DisordersThis policy governs coverage of wireless capsule endoscopy, primarily for evaluation of the small bowel in members with suspected bleeding, Crohn's disease, hereditary GI polyposis syndromes, or celiac disease. It also identifies capsule endoscopy uses and related capsule technologies considered investigational and specifies documentation needed for medical-necessity review.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Bronchial ValvesCoverage of bronchial valve placement, removal, replacement, and revision for severe emphysema, including medical necessity requirements for providers.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Deep Brain StimulationThis policy governs coverage of unilateral or bilateral deep brain stimulation, including medical-necessity criteria and documentation requirements for neurologic conditions.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Mental Health and Eating DisordersThis policy establishes medical necessity criteria, treatment expectations, level-of-care requirements, and documentation requirements for mental health and eating disorder services. It applies to providers seeking initial or continued authorization for acute inpatient, residential, partial hospitalization, and intensive outpatient services.All regence updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Testosterone TestingThis policy governs coverage of total, free, and bioavailable testosterone testing for diagnosing androgen deficiency or excess and for establishing baselines or monitoring treatment response. It applies to providers submitting testosterone testing for individuals with relevant symptoms, disorders, or specified treatments.All regence updates
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Tool Description
Search Regence 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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