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Coverage criteria policies

CoOportunity Health has Medical Policies that contain coverage criteria and guidelines that describe how we make coverage decisions for certain health care services and items. Please call our Member Services Department at 1.888.324.2064 if you have any questions.

The information presented regarding coverage criteria and guidelines is regularly updated and is subject to change without notice.  Read moreā€¦

If unsure of the keyword spelling, enter the first three letters of the word followed by an asterisk (*). Example: enter acu* to locate the acupuncture policy.

Policy search filters

Viewing 38 of 422 policies
Policy name Policy category Product Prior authorization required
Sacral nerve stimulation for fecal incontinenceMedical ServicesCoOportunity Health
Iowa
Nebraska
No
Sacroiliac joint pain treatment proceduresMedical Services
Spine
CoOportunity Health
Iowa
Nebraska
Yes
Saline or sterile waterEquipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
ScalesEquipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Scar revision/keloidsSurgeryCoOportunity Health
Iowa
Nebraska
No
Seating support orthosis (SSO)Equipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Selective nerve root block for diagnoses of chronic low back pain with radiculopathyMedical Services
Spine
CoOportunity Health
Iowa
Nebraska
Yes
Sex therapyBehavioral HealthCoOportunity Health
Iowa
Nebraska
Yes
Sexual dysfunction - medical treatmentMedical ServicesCoOportunity Health
Iowa
Nebraska
No
ShoesEquipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Short term treatment of acute psychiatric illness criteriaBehavioral HealthCoOportunity Health
Iowa
Nebraska
No
Shoulder resurfacingInvestigational
Surgery
Medical Services
CoOportunity Health
Iowa
Nebraska
No
Silicone gel sheetingEquipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Siltuximab (Sylvant®)PharmacyCoOportunity Health
Iowa
Nebraska
Yes
Sipuleucel-T (Provenge®)PharmacyCoOportunity Health
Iowa
Nebraska
Yes
Sitz bathsEquipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Skilled nursing facilityAncillary ServicesCoOportunity Health
Iowa
Nebraska
Yes
Sleep study (polysomnogram)Medical ServicesCoOportunity Health
Iowa
Nebraska
No
Snoring treatmentMedical ServicesCoOportunity Health
Iowa
Nebraska
No
SpacersEquipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Specialty mattress replacement/overlay (group I)Equipment/SuppliesCoOportunity Health
Iowa
Nebraska
Yes
Speech therapy – habilitativeAncillary ServicesCoOportunity Health
Iowa
Nebraska
Yes
Speech therapy – rehabilitativeAncillary ServicesCoOportunity Health
Iowa
Nebraska
No
Spinal cord stimulator (SCS)Surgery
Spine
CoOportunity Health
Iowa
Nebraska
Yes
Spinal fusion – lumbarSurgery
Spine
CoOportunity Health
Iowa
Nebraska
Yes
Spinal laminectomyMedical Services
Spine
Surgery
CoOportunity Health
Iowa
Nebraska
No
Spinal unloading devicesEquipment/Supplies
Spine
CoOportunity Health
Iowa
Nebraska
No
Splints – durable (long term)Equipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Splints – supply (short term)Equipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Standing frame/standerEquipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Stereotactic radiosurgerySurgeryCoOportunity Health
Iowa
Nebraska
Yes
SterilizationMedical Services
Preventive
CoOportunity Health
Iowa
Nebraska
No
Strabismus surgerySurgeryCoOportunity Health
Iowa
Nebraska
No
Sublingual immunotherapy (SLIT)PharmacyCoOportunity Health
Iowa
Nebraska
Yes
Suction machine and catheterEquipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Sun tanning boothsEquipment/SuppliesCoOportunity Health
Iowa
Nebraska
No
Sympathectomy (thoracic) for the treatment of primary hyperhidrosisSurgeryCoOportunity Health
Iowa
Nebraska
Yes
Synagis (palivizumab) injections for respiratory syncytial virus (RSV) prophylaxis - Effective 11/1/14Medical Services
Pharmacy
CoOportunity Health
Iowa
Nebraska
Yes
Viewing 38 of 422 policies
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