West Virginia Bureau For Medical Services (Department Of Human Services) Coverage Criteria
- West Virginia Bureau For Medical Services (Department Of Human Services) prior authorization
- West Virginia Bureau For Medical Services (Department Of Human Services) timely filing
- All West Virginia Bureau For Medical Services (Department Of Human Services) policy updates
Latest West Virginia Bureau For Medical Services (Department Of Human Services) coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Chapter 504 — Substance Use Disorder Services (Coverage Criteria)Governance of Medicaid-covered substance use disorder services in West Virginia, including provider enrollment, clinical and administrative requirements, medical necessity, prior authorization, and program structure affecting enrolled providers and Medicaid members.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Prior Authorization Criteria — Wegovy (semaglutide)Prior authorization criteria for coverage of Wegovy (semaglutide) under the West Virginia Bureau for Medical Services, limited to secondary prevention of major adverse cardiovascular events and treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH). Affects prescribers requesting PA for WV BMS beneficiaries.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-19Prior Authorization Criteria — DUPIXENT (dupilumab)This document defines prior authorization requirements and clinical criteria for coverage of Dupixent (dupilumab) across its FDA-indicated uses for West Virginia Bureau for Medical Services members. It applies to prescribers requesting PA for Dupixent under the payer's pharmacy prior authorization process.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-19Prior Authorization Criteria — Ebglyss (lebrikizumab-lbkz) for Moderate-to-Severe Atopic DermatitisPrior authorization criteria for coverage of Ebglyss (lebrikizumab-lbkz) for patients with moderate-to-severe atopic dermatitis, specifying prescriber qualifications, diagnostic documentation, prior topical therapy trials, age/weight eligibility, and approval durations.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-26Criteria for Approval: Casgevy (exagamglogene autotemcel) Prior AuthorizationDefines prior authorization requirements and medical necessity criteria for one-time administration of Casgevy (autologous genome-edited HSC gene therapy) for patients with sickle cell disease (SCD) with recurrent vaso-occlusive crises and transfusion-dependent β-thalassemia (TDT), affecting providers and members seeking coverage under West Virginia Bureau for Medical Services.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-01OBMAT (Office-Based Medication Assisted Treatment) coverage criteriaGoverns Medicaid coverage and provider requirements for office-based medication assisted treatment (OBMAT), related counseling/therapy, and alignment with state/federal regulations for West Virginia Medicaid providers.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-01Continuous Glucose Monitors (Freestyle Libre & Dexcom) — Prior Authorization CriteriaPrior authorization criteria for coverage of specified continuous glucose monitors (CGMs) under West Virginia Medicaid, detailing initial approval, reauthorization, and special pediatric provisions. Applies to providers requesting CGM coverage for WV Medicaid members.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-11-13Prior authorization criteria for Opzelura (ruxolitinib) topicalDefines prior authorization requirements and clinical criteria for coverage of topical ruxolitinib (Opzelura) for mild to moderate atopic dermatitis in patients meeting FDA age indications, for West Virginia Bureau for Medical Services members.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-10-01Mammography (Coverage Criteria)Defines West Virginia Medicaid coverage, requirements, and exclusions for screening and diagnostic mammography (including digital breast tomosynthesis) and related facility/provider requirements; applies to West Virginia Medicaid members and providers.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-01Bone Density Testing (DXA and related modalities) — Coverage CriteriaDefines coverage, limitations, and non-covered bone density testing services for West Virginia Medicaid members, and outlines prior authorization and documentation requirements for providers.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-01Wound Care — Negative Pressure Wound Therapy (NPWT) and Biologics CoverageDefines West Virginia Medicaid coverage, prior authorization, medical necessity criteria, covered wound biologics and devices, and non-covered wound modalities for enrolled providers and beneficiaries.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-03-16Tobacco Cessation Services Coverage CriteriaDefines West Virginia Medicaid coverage for tobacco cessation medications, nicotine replacement therapies, and counseling/coaching programs for Medicaid members enrolled in approved telephone coaching programs; applies to Fee-for-Service and Managed Care enrollees.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-03-16Tobacco Cessation Services — Coverage and Clinical CriteriaCoverage and clinical/administrative rules for tobacco cessation medications, nicotine replacement therapies, and counseling/coaching available to West Virginia Medicaid members, including FFS and Managed Care enrollees.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-01Psychiatric Residential Treatment Facilities (PRTF) coverage criteria and provider requirementsGoverns PRTF program requirements, admission/denial processes, staffing, assessment tools, and discharge/continuity requirements for WV Medicaid members and facilities serving them.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-09-01CHAPTER 519.24 Gender Affirmation SurgeryDefines West Virginia Medicaid coverage, medical necessity criteria, prior authorization, and documentation requirements for gender affirmation surgical procedures for members with Gender Dysphoria age 21 and older.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-09-01Comments for Chapter: 519.24 Gender Affirmation SurgeryPublic comments and agency responses regarding Chapter 519.24 on coverage of gender-affirming surgery for West Virginia Medicaid members; clarifies surgical coverage scope and related questions such as hormone therapy and provider qualifications.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-01-01Podiatry (Foot and Ankle) Services Coverage CriteriaDefines West Virginia Medicaid coverage, prior authorization, and exclusions for podiatric services (examination, diagnosis, treatment, prevention, and care of the foot and ankle) provided by licensed podiatrists eligible to participate in WV Medicaid.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-06-01Omnipod Insulin Management System prior authorizationPrior authorization criteria for coverage of the Omnipod insulin management system for West Virginia Bureau for Medical Services members; describes clinical and documentation requirements for initial and continued coverage.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-05-26Amondys 45 (casimersen) prior authorization for Duchenne muscular dystrophyDefines prior authorization requirements and coverage criteria for Amondys 45 for patients with Duchenne muscular dystrophy who have a DMD gene mutation amenable to exon 45 skipping; applies to requests reviewed by West Virginia Bureau for Medical Services Pharmacy Prior Authorization.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-05-01CHAPTER 509 — Hospice Services (Coverage Criteria)Defines West Virginia Medicaid coverage, provider participation, staffing, service types, benefit periods, and administrative requirements for hospice services for eligible West Virginia Medicaid members.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-05-01Comments and updates to Chapter 509 Hospice Services (Coverage Criteria)Comments and resulting updates to West Virginia Medicaid Chapter 509 Hospice Services outlining provider participation, service requirements, benefit periods, enrollment/certification timelines, billing/reimbursement categories, and coordination with waiver and PCS programs; affects hospice providers serving WV Medicaid members.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-01-01Prior Authorization Criteria — BOTOX® (onabotulinumtoxinA) / Botulinum toxinPrior authorization and medical necessity criteria for onabotulinumtoxinA (BOTOX®) billed under J0585–J0588, describing covered indications by ICD-10 diagnosis for West Virginia Bureau for Medical Services.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-09-01Applied Behavior Analysis (ABA) — Coverage CriteriaGoverns coverage, provider qualifications, prior authorization, assessment, and billing rules for ABA services provided to West Virginia Medicaid members (children with ASD). Affects enrolled ABA providers and managed care/utilization management reviewers.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-07-15CHAPTER 503 — Licensed Behavioral Health Centers (LBHC) Coverage CriteriaRules and requirements for provision, enrollment, documentation, and reimbursement of Licensed Behavioral Health Center services under West Virginia Medicaid for enrolled providers delivering outpatient behavioral health and rehabilitation services.All West Virginia Bureau for Medical Services (Department of Human Services) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-07-01CHAPTER 504: Substance Use Disorder (SUD) Waiver Services — Coverage CriteriaGoverns Medicaid coverage, provider enrollment, medical necessity, supervision, and program integrity requirements for SUD Waiver Services provided to West Virginia Medicaid members, including members in managed care and foster care.All West Virginia Bureau for Medical Services (Department of Human Services) updates
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Tool Description
Search West Virginia Bureau For Medical Services (Department Of Human Services) 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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