Medical policies

Select a PDF or Word doc below to see medical necessity criteria for a specific treatment or service.

Medical policy listings

A - E
Absorbent Products for Incontinence
Acupuncture
Acute Inpatient
Arthrodesis-for-Sacroiliac-Joint-Pain
Artificial Pancreas Device System
Assisted Reproductive Services/Infertility Services
Autologous Chondrocyte Implantation in the Knee
Bariatric Surgery
Bone Growth Stimulator
Breast Surgeries
Breast Surgeries(Effective Date: December 2020)
Bronchial Thermoplasty
Cardiac Imaging (outpatient) (eviCore evidence based Clinical Guidelines)
Chiropractic Services
Continuous Airway Devices (CareCentrix Guidelines)
Continuous Glucose Monitors
Corneal Collagen Cross-linking
Definition of Skilled Care
Dental Treatment Setting
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) (Effective Date: October 2020)
Enteral Nutrition Formulas and Supplements
Enteral Nutrition Formulas and Supplements (Effective Date: December 2020)
Experimental and Investigational
Extended Care Facility
External-Counterpulsation
F - M
Gender Affirming Procedures
Genetic Molecular Genome Testing (eviCore evidence-based Clinical Guidelines)
Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome (Refer to the eviCore clinical guidelines)
Hearing Devices
HIV-Associated Lipodystrophy Syndrome
Home Health Care
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
Home Prothrombin Time Monitoring
Insulin Pumps
Kymriah
Lutathera (lutetium Lu 177 dotatate)
Luxturna
Macimorelin (Macrilen®)
Mobile Cardiac Outpatient Telemetry
N - Z
Neuromodulation for Overactive Bladder
Non-Emergency Medically Necessary Transportation
Oral and Maxillofacial Surgery and Procedures
Out of Network Providers
Outpatient Chest Physical Therapy
Outpatient Drug Screening and Testing
Phototherapeutic Keratectomy
Phototherapy & Photo Chemotherapy for Dermatologic Conditions
Preimplantation Genetic Testing
Prostatic Urethral Lift
Prostheses — Lower Limb
Prostheses — Upper Limb
Provenge
Radiation Therapy (outpatient) (eviCore evidence-based Clinical Guidelines)
Radiology (eviCore healthcare evidence-based Clinical Guidelines)
Reconstructive and Cosmetic Procedures (Effective Date: March 2020)
Sleep Studies (CareCentrix Guidelines)
Specialty Medication Administration — Site of Care (For Ocrevus, Tysabri, Kanuma, and Ultomiris medication requests)
Specialty Medication Administration — Site of Care (Use for medications excluding Ocrevus, Tysabri, Kanuma, and Ultomiris)
Speech Generating Devices
Therapeutic Lens
Ultrasound (Non-Obstetric) (eviCore evidence-based Clinical Guidelines)
UVB Home Phototherapy Units for Skin Disease
Vitamin D Screening and Testing in Adults
Yescarta
Zolgensma

Clinical criteria do not certify coverage availability.

Please refer to the current AllWays Health Partners provider manual for a definition of “medical necessity.” Criteria may be amended or rescinded at any time by AllWays Health Partners and AllWays Health Partners shall have the exclusive right to interpret and enforce its terms.

Confirming coverage
is easy

To verify services under a specific plan or to ask about guidelines not listed here, simply contact Provider Services at 800-462-5449.

Medical policies

Select a PDF or Word doc below to see medical necessity criteria for a specific treatment or service.

Medical policy listings

Confirming coverage is easy

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Confirming coverage
is easy