Univerahealthcare Coverage Criteria
Latest Univerahealthcare coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Artificial Cervical Intervertebral DiscThis policy governs medical necessity and coverage criteria for initial/primary total artificial cervical intervertebral disc implantation for patients with radiculopathy or myelopathy. It affects providers seeking authorization for cervical disc arthroplasty at covered levels.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Artificial Lumbar Intervertebral Disc (Lumbar Total Disc Arthroplasty)Defines medical necessity criteria and exclusions for initial primary lumbar total disc arthroplasty (single-level) and references fusion after failed arthroplasty; affects providers submitting requests for coverage under Univera Healthcare.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Autologous Chondrocyte Implantation (ACI)Defines medical necessity criteria and exclusions for autologous chondrocyte implantation (ACI)/matrix-induced ACI (MACI) for focal full-thickness chondral defects of the knee, and specifies provider requirements for patient selection.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Continuous Positive Airway Pressure (CPAP) and Auto-Adjusting Positive Airway Pressure (APAP) DevicesDefines medical necessity criteria and coverage rules for Continuous Positive Airway Pressure (CPAP) and Auto-Adjusting Positive Airway Pressure (APAP) devices for adults and children with obstructive sleep apnea, including initial 90-day trials and continuation requirements.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Epidural Steroid Injections / Selective Nerve Root Block (SNRB)Defines medical necessity, investigational uses, and appropriateness criteria for diagnostic and therapeutic selective nerve root blocks for radicular pain/radiculopathy.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Hip Arthroplasty (partial and total hip replacement)Medical necessity criteria and exclusions for partial (hemi) and total hip replacement procedures; governs coverage determinations for members receiving hip arthroplasty.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Home Non-Invasive Positive Pressure Ventilation (NIPPV) Devices for Respiratory Insufficiency and FailureMedical necessity and coverage criteria for home non-invasive positive pressure ventilation devices (BPAP and non-invasive home mechanical ventilation) for individuals with respiratory insufficiency due to neuromuscular or thoracic restrictive disease.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Lumbar DecompressionDefines medical necessity criteria for primary lumbar decompression procedures for indications including neurogenic claudication and radiculopathy; applies to Univera Healthcare covered members and their providers.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Lumbar Fusion (arthrodesis) with decompressionDefines medical necessity criteria for lumbar fusion with direct or indirect decompression in adult patients, including imaging and perioperative requirements for instability and anticipated iatrogenic instability.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Lumbar MicrodiscectomyClinical criteria and medical necessity guidance for initial primary lumbar microdiscectomy (laminotomy, laminectomy, or hemilaminectomy) for members; applies to providers requesting coverage for these procedures.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Magnetic Resonance Imaging (MRI) of the ProstateClinical criteria for when pelvic MRI (with or without contrast) of the prostate is considered medically appropriate for men with suspected prostate cancer; intended for providers and authorization staff.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD)Defines medical necessity criteria for magnetic sphincter augmentation (e.g., LINX) to treat GERD and states that use for other indications is investigational; applies to Univera Healthcare benefit determination and providers seeking coverage.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Metal-on-Metal Total Hip ResurfacingPolicy governs medical necessity criteria and exclusions for FDA‑approved metal-on-metal total hip resurfacing devices for members, specifying clinical, imaging, age, and prior non-surgical management requirements.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Osteochondral Grafting of the KneeDefines medical necessity criteria, investigational determinations, and related policy references for osteochondral allograft/autograft transplantation (OATS)/mosaicplasty of the knee for Univera Healthcare members and providers.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous SacroplastyDefines medical necessity criteria for vertebral augmentation (PMMA cement injection) and percutaneous sacroplasty for malignant and non-malignant vertebral conditions and for use associated with fusion surgery; applies to Univera Healthcare members and providers evaluating coverage.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Positron Emission Tomography (PET) - Non-Oncologic ApplicationsDefines medical appropriateness criteria for PET/CT and cardiac PET perfusion imaging for non-oncologic indications (abdominal, retroperitoneal, splenic, lymphoproliferative, cardiac) affecting providers requesting or performing these studies for Univera Healthcare members.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Positron Emission Tomography (PET) Oncologic ApplicationsDefines medical necessity criteria for FDG PET and PET/CT in oncologic indications across multiple cancer types for Univera Healthcare members and providers.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing)Criteria for medical necessity, non-coverage, and investigational status for shoulder arthroplasty procedures (total, hemi/partial, reverse, revision, and resurfacing) applicable to Univera Healthcare members and providers.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-15Spinal Cord Stimulation / Dorsal Column StimulationDefines medical necessity criteria for short-term trial and permanent implantation of non-high-frequency and high-frequency (HF10) spinal cord stimulators for indications including Failed Back Surgery Syndrome and Painful Diabetic Peripheral Neuropathy; intended for providers requesting authorization and coverage determinations.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-17External Prosthetic DevicesGoverns medical necessity and coverage criteria for external prosthetic devices and related supplies for Univera Healthcare members; excludes implantable prosthetics and orthotic devices and applies to external prostheses for upper and lower limbs and related supplies.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-17Non-Invasive Prenatal Testing (NIPT)This policy governs coverage and medical necessity criteria for non-invasive prenatal testing (cell-free fetal DNA) and related first-trimester screening methods for pregnant members; it affects providers ordering prenatal genetic screening and Univera Healthcare members.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-16Balloon Dilation of the Eustachian Tube (BDET)Defines when BDET is considered medically appropriate or investigational for treatment of chronic obstructive Eustachian tube dysfunction (ETD) for Univera Healthcare members and what diagnostic and treatment history criteria must be met.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-16Chiropractic CareThis policy governs coverage and medical necessity criteria for chiropractic care provided by a licensed Doctor of Chiropractic (DC) for neuromusculoskeletal conditions. It applies to Univera Healthcare benefit determinations for members receiving chiropractic services.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-16Dental Crowns and VeneersDefines medical necessity criteria for traditional/3/4 dental crowns and anterior dental veneers for Univera Healthcare members.All univerahealthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-16Dental ImplantsCriteria and coverage guidance for dental implant placement, including when single implants, implant-supported dentures, and related services are considered medically appropriate or not for Univera Healthcare members.All univerahealthcare updates
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Tool Description
Search Univerahealthcare 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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