Wellpoint Coverage Criteria
Latest Wellpoint coverage criteria updates25
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-06-11Modifier 24Reimbursement for evaluation and management services billed with modifier 24 during the postoperative period of an original procedure in Iowa.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01TeledentistryCoverage and delivery requirements for dental diagnostic, consultative, educational, preventive, imaging, and limited dental services provided through synchronous or asynchronous teledentistry.All wellpoint updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2024-05-22Transportation Services: Ambulance and Non-Emergent TransportReimbursement requirements for ambulance and non-emergency medical transportation to and from covered or contract-mandated services in New Jersey Medicaid, including coverage criteria, exclusions, billing modifiers, and transportation levels of care.All wellpoint updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2023-12-19Transportation Services: Ambulance and Non-Emergent TransportWashington Medicaid reimbursement for ambulance and non-emergency medical transportation to and from covered or contractually mandated services, including coverage criteria, nonreimbursable services, billing requirements, and transportation modifiers.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyAdult chiropractic clinical guideline for TennesseeMedical-necessity, coverage, authorization, coding, contraindication, and documentation requirements for chiropractic services provided to adults enrolled in Wellpoint Tennessee Medicaid.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyAnesthesiaThis policy governs coverage considerations, medical necessity, clinical criteria, monitoring, documentation, and coding for local anesthesia, nitrous oxide, conscious sedation, deep sedation, and general anesthesia provided with dental services. It applies to dental providers and members, subject to the member's contract benefits and applicable federal and state law.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyAnesthesia GuidelineThis guideline governs coverage considerations, medical necessity, clinical criteria, monitoring, documentation, and coding for local anesthesia, nitrous oxide, moderate sedation, deep sedation, and general anesthesia used with dental services.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyBiological Materials to Aid in Soft and Osseous Tissue RegenerationThis policy governs the documentation, clinical circumstances, and coding considerations for biological materials used alone or with other procedures to aid soft-tissue and osseous-tissue regeneration in dentistry. It applies to dental services, including regenerative treatment of periodontal defects involving natural teeth and dental implants, when covered under the applicable group contract.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyBone Grafts for Dental and Oral Surgical ServicesCoverage review for bone graft procedures involving the jaw, maxilla, mandible, and oral/maxillofacial region, including documentation, medical necessity, and benefit eligibility.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyBone Grafts for Dental and Oral Surgical ServicesThis guideline governs coverage review, clinical criteria, documentation, and coding for bone grafting and related grafting procedures involving the jaw, maxilla, mandible, implant sites, and oral or maxillofacial defects. It applies to submitting dentists and is subject to the member’s benefit plan, contract terms, and applicable law.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyCaries Arresting Medicament ApplicationThis dental clinical policy governs conservative topical application of a caries-arresting or inhibiting medicament to active, non-symptomatic carious lesions without mechanical removal of sound tooth structure. It provides guidance for providers and benefit determination, subject to the member's contract and applicable law.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyCaries Arresting Medicament ApplicationThis policy governs the clinical criteria and coding guidance for topical application of a caries-arresting or inhibiting medicament on a per-tooth basis for active, non-symptomatic carious lesions. It applies to providers submitting dental services, subject to the member's applicable contract benefits.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyClinical Utilization Management GuidelinesThis document identifies the Clinical Utilization Management Guidelines adopted by Wellpoint for New Jersey Medicaid members and explains which clinical criteria sources are used for medical-necessity, site-of-service, and related utilization reviews. Determinations are made case by case under applicable Medicaid contracts, regulatory guidance, CMS requirements, and Wellpoint medical-necessity policies.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyClinical Utilization Management GuidelinesApplies to providers serving Wellpoint Washington Medicaid members and explains how medical necessity, site-of-service, and related utilization reviews are conducted using applicable policies, InterQual, MCG, or ASAM criteria.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyCore Buildup - Includes Post and Core ProceduresThis policy guides coverage and medical-necessity review for core buildups, prefabricated and indirectly fabricated post-and-core procedures, and related post removal. It applies to providers submitting these services, subject to the member’s contract benefits and applicable law.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyCrowns, Inlays, and OnlaysDental coverage consideration and documentation requirements for indirect restorations, including crowns, inlays, and onlays, subject to the member’s contract and plan-specific provisions.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyGenerally Accepted Standard of Dental CareThis guideline governs review of dental services requested or rendered for covered members to determine whether they meet generally accepted standards of dental care and contractual benefit requirements. Dental necessity or appropriateness alone does not guarantee that a service is covered or payable.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyGingival Flap Procedure and Apically Positioned FlapThis policy governs coverage criteria, documentation, coding, and limitations for gingival flap procedures and apically positioned flaps used to treat periodontal disease under Wellpoint plans.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyGingival Flap Procedure and Apically Positioned Flap GuidelineThis policy governs clinical criteria, documentation, limitations, and coding guidance for gingival flap procedures and apically positioned flaps used to treat periodontal disease under Wellpoint dental benefits, subject to the member’s contract.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyGingivectomy and Gingivoplasty GuidelinesThis policy governs the clinical appropriateness, documentation, limitations, contraindications, and coding of gingivectomy and gingivoplasty procedures for dental members. It applies to providers submitting these procedures for periodontal treatment, gingival recontouring, or restorative access.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyGingivectomy or GingivoplastyThis policy governs the clinical appropriateness, documentation, coding, and benefit considerations for gingivectomy and gingivoplasty services for Wellpoint members, subject to member contract benefits and applicable law.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyGuided Tissue RegenerationThis policy governs clinical indications, documentation, coverage limitations, and coding for guided tissue regeneration procedures in dental and oral/maxillofacial care. Coverage is subject to the member’s contract, and federal or state law and contract language take precedence.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyImplant/Abutment Supported Removable ProstheticsCoverage consideration, clinical criteria, documentation, coding, and benefit limitations for implant/abutment supported removable prosthetics used to replace missing teeth.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyImplant/Abutment Supported Removable Prosthetics GuidelinesThis dental clinical policy governs coverage consideration and clinical criteria for removable prosthetics supported by dental implants or abutments, including replacement of missing teeth. Final coverage depends on the member’s plan benefits and contract.All wellpoint updates
- Coverage CriteriaClinical/Medical PolicyManagement of Peri-Implant DefectsThis Dental Clinical Policy describes the clinical evaluation, documentation, and treatment approaches for peri-implant mucositis, peri-implantitis, and other inflammatory defects surrounding osseointegrated dental implants. It provides guidance for reviewing dental services and does not itself establish member-specific coverage or reimbursement.All wellpoint updates
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Tool Description
Search Wellpoint 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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