UnitedHealthcare Coverage Criteria
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Latest UnitedHealthcare coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Alyftrek (vanzacaftor/tezacaftor/deutivacaftor) prior authorizationPrior authorization and medical necessity criteria for Alyftrek for treatment of cystic fibrosis in patients aged 6 years and older; applies to UnitedHealthcare pharmacy benefits and providers requesting coverage.All UnitedHealthcare updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-08-01Ambulance Services (for Nebraska Only)Defines UnitedHealthcare Community Plan's policy on ambulance services that applies only to Nebraska members and references Nebraska DHHS Code §471-4 for medical necessity criteria.All UnitedHealthcare updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-08-01Ambulance Services (for North Carolina Only)Defines UnitedHealthcare Community Plan reimbursement policy for ambulance services applicable only to North Carolina members; aligns coverage criteria to North Carolina Medicaid Clinical Coverage Policy.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Bariatric Surgery (for Nebraska Only)Nebraska-specific UnitedHealthcare medical policy governing coverage criteria and coding for bariatric surgery and related procedures for Community Plan members in Nebraska.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Beds and Mattresses (for Idaho Only)State-specific UnitedHealthcare medical policy governing coverage criteria for hospital beds, specialty beds, safety enclosures, and related accessories for members in Idaho, including Idaho Medicaid Plus plans.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Beds and Mattresses (for Kansas Only)Policy governing medical necessity and coverage references for beds and mattresses for UnitedHealthcare Community Plan members in Kansas; directs providers to the Kansas Medical Assistance Program DME Fee-For-Service Provider Manual for clinical criteria.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Beds and Mattresses (for New Mexico Only)Defines UnitedHealthcare Community Plan coverage and clinical criteria for hospital beds, specialty beds, support surfaces, and safety enclosures in New Mexico members.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Beds and Mattresses (for North Carolina Only)Defines UnitedHealthcare Community Plan coverage guidance for beds and mattresses (durable medical equipment) applicable to North Carolina Medicaid members, referencing the NC Medicaid Clinical Coverage Policy for clinical criteria.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Breast Reduction Surgery (for Tennessee Only)Policy governs coverage of breast reduction (reduction mammaplasty) for Medicaid and CoverKids members in Tennessee, outlining applicability, coding, documentation expectations, and reference to TennCare medical necessity criteria.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Carrier Testing Panels for Genetic Diseases (for Kansas Only)Policy governs coverage and use of carrier testing panels for genetic diseases for UnitedHealthcare Community Plan members in Kansas; it references Kansas Medical Assistance Program clinical criteria and applies only to Kansas.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Cell-Free Fetal DNA Testing (for Idaho Only)Defines UnitedHealthcare Community Plan coverage guidance for cell-free fetal DNA testing for members in Idaho, including Idaho Medicaid Plus plans; references Idaho Medicaid Provider Handbook for clinical criteria.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Cell‑Free Fetal DNA Testing (for Kansas Only)Policy governing coverage and clinical documentation expectations for DNA-based noninvasive prenatal tests (cfDNA) for fetal aneuploidy and related testing for members covered under UnitedHealthcare in the state of Kansas.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Chromosome Microarray Testing (Non-Oncology Conditions) (for Idaho Only)State-specific UnitedHealthcare medical policy for chromosome microarray testing (aCGH/SNP array) for non-oncology conditions that applies only to Idaho members, including Idaho Medicaid Plus plans, describing coverage rationale, applicable codes, and documentation expectations.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Chromosome Microarray Testing (Non-Oncology Conditions) (for Pennsylvania Only)Policy governs coverage and medical necessity criteria for chromosome microarray testing (aCGH/SNP array/low-pass sequencing) for non-oncology indications for UnitedHealthcare Community Plan members in Pennsylvania.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Complement Pathway InhibitorsDefines UnitedHealthcare medical benefit drug coverage rules for specified complement pathway inhibitors (C5 and related agents) and the clinical criteria required for authorization. Applies to UnitedHealthcare plans except where state-specific exclusions are listed.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Kansas Only)Policy governing coverage and clinical criteria for continuous glucose monitors (CGMs) and insulin delivery devices for members in Kansas; references Kansas Medical Assistance Program criteria and applies only to Kansas.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Nebraska Only)This policy governs medical necessity criteria, coverage rationale, and coding for continuous glucose monitoring (CGM) devices and insulin delivery systems for UnitedHealthcare members in Nebraska.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for New Mexico Only)Defines UnitedHealthcare medical policy for continuous glucose monitoring (CGM) and insulin delivery devices and coverage criteria applicable to members in New Mexico.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Pennsylvania Only)Policy governs coverage and medical necessity criteria for continuous glucose monitoring (CGM) and insulin delivery devices for Pennsylvania Medicaid and CHIP members; it directs providers to state-specific handbook and InterQual criteria for detailed prior authorization guidance.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Copiktra (duvelisib) prior authorizationPrior authorization and coverage criteria for Copiktra (duvelisib) for treatment of relapsed/refractory CLL/SLL and certain T-cell lymphomas; applies to UnitedHealthcare pharmacy benefit members and prescribers requesting coverage.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Cosmetic and Reconstructive Procedures (for Kentucky Only)Defines when procedures are considered reconstructive (medically necessary) versus cosmetic for UnitedHealthcare members in Kentucky and lists related policies and applicable billing codes. Applies to providers reviewing coverage for Kentucky members.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Daybue (trofinetide) prior authorization for Rett syndromeThis policy governs prior authorization and medical necessity criteria for Daybue (trofinetide) for treatment of Rett syndrome in beneficiaries of UnitedHealthcare. It affects prescribers and pharmacies seeking authorization for initial and continued therapy.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Dojolvi (triheptanoin) prior authorizationPrior authorization and medical necessity criteria for Dojolvi (triheptanoin) for treatment of long-chain fatty acid oxidation disorders (LC-FAOD) for UnitedHealthcare members; affects prescribers requesting coverage.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Dojolvi (triheptanoin) prior authorizationDefines prior authorization requirements and coverage criteria for Dojolvi (triheptanoin) for members with long-chain fatty acid oxidation disorders (LC-FAOD). Applies to UnitedHealthcare pharmacy benefit prior authorization processes.All UnitedHealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Electric Tumor Treatment Field Therapy (for Ohio Only)This policy governs coverage and medical necessity criteria for electric tumor treatment field (TTF) therapy for members of UnitedHealthcare Community Plan in the state of Ohio.All UnitedHealthcare updates
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Tool Description
Search UnitedHealthcare 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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