Oscar Clinical Guidelines: Medical
Clinical guidelines are developed and adopted to establish evidence-based clinical criteria for utilization management decisions. Oscar may delegate utilization management decisions of certain services to third-party delegates, who may develop and adopt their own clinical criteria.Clinical guidelines are applicable to certain policies. Clinical guidelines are applicable to members enrolled in Medicare Advantage plans only if there are no in-force criteria for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of a prior authorization request. Coverage of services is subject to the terms, conditions, limitations of a member’s policy and applicable state and federal law. Please reference the member’s policy documents (e.g., Certificate/Evidence of Coverage, Schedule of Benefits) or to confirm coverage contact 855-672-2755 for Oscar Plans and 855-672-2789 for Cigna+Oscar Plans.Looking for Pharmacy Guidelines? Click here.
Medical Guidelines
- Acupuncture (CG013)
- Aduhelm (aducanumab-avwa) (PG139)
- Allergy Immunotherapy (CG059)
- Ambulatory Cardiac Event Monitoring (CG032)
- Ambulance Services (CG057)
- Anesthesia and Sedation in Endoscopy (CG041)
- Approved and Accepted Off-label Medical Necessity Criteria for Products, Drugs and Biologicals (PG136)
- Apretude (cabotegravir extended-release injectable suspension) (PG158)
- Autonomic Testing (CG026)
- Bariatric Surgery (Adults) (CG008)
- Bariatric Surgery (Adolescents) (CG009)
- Beyfortus (nirsevimab-alip) (PG180)
- Bioengineered Skin and Soft Tissue Substitutes (CG030)
- Botulinum Toxin (CG033)
- BPH Treatment (CG031)
- Breast Imaging (CG027)
- Breast Procedures (CG036)
- Breast Pumps - Manual and Electric (CG002)
- Balloon Ostial Dilation (CG018)
- Briumvi (ublituximab) (PG134)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) CAR T-cell (CG067)
- Collagenase Ointment (Santyl) (PG141)
- Colorectal Cancer Screening (CG024)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052)
- Concomitant use of Biologics and tsDMARDs (CG064)
- Contact Lenses and Eyeglasses (CG039)
- COVID-19 Antibody Testing (CG077)
- Deep Brain Stimulation and Responsive Neurostimulation (CG050)
- Diabetes Equipment and Supplies (CG028)
- Elevidys (delandistrogene moxeparvovec-rokl) (PG160)
- Erectile Dysfunction (CG037)
- Enteral and Oral Liquid Nutritional Supplements (CG011)
- Experimental and Investigational Services (CG012)
- Glaucoma Surgery (CG034)
- Hearing Aids (CG001)
- Hemgenix (etranacogene dezaparvovec) (CG075)
- Home Births and Birth Centers (CG038)
- Home Care - Home Health Aides (CG022)
- Home Care - Skilled Nursing Care (RN, LVN/LPN) (CG020)
- Home Care - Physical Therapy/Occupational Therapy (CG021)
- Home Care - Speech Language Pathology (CG023)
- Hospital Beds and Accessories (CG006)
- Hyperbaric Oxygen Therapy (CG014)
- Hypoglossal Nerve Stimulation (CG065)
- Infertility Treatment (CG016)
- Insulin Delivery Systems and Continuous Glucose Monitoring (CG029)
- Intraoperative Neuromonitoring (CG045)
- Ilumya (tildrakizumab-asmn) (CG053)
- Izervay (avancincaptad pegol) (PG168)
- Kymriah (tisagenlecleucel) (CG058)
- Lamzede (velmanase alfa-tycv) (PG146)
- Lantidra (donislecel-jujn) (PG167)
- Leqembi (lecanemab-irmb) (PG138)
- Long-Term Acute Care Hospital (LTACH) (CG062)
- Luxturna (voretigene neparvovec-rzyl) (CG060)
- (Medicare Part B Step Therapy) Preferred Physician-Administered Specialty Drugs (CG066)
- Medical Nutrition Therapy (CG010)
- NexoBrid (anacaulase-bcdb) (CG112)
- Negative Pressure Wound Therapy and Negative Pressure Infusion Therapy (CG068)
- Noninvasive Positive Pressure Ventilation (CG003)
- Omisirge (omidubicel-onlv) (PG149)
- Optical Coherence Tomography (CG025)
- Oxygen Therapy (CG005)
- Outpatient Physical Therapy & Occupational Therapy (CG044)
- Pain Management: Epidural Steroid Injections, Selective Nerve Root Blocks (SNRB), and Intradiscal Steroid Injections (CG048)
- Pain Management: Facet Joint Injections and Radiofrequency Facet Denervation (CG047)
- Pain Management: Sacroiliac Intra-Articular Joint Injections (CG056)
- Pedmark (sodium thiosulfate) (PG133)
- Pneumatic Compression Pumps (CG049)
- Prenatal Testing (CG043)
- Prescription Digital Therapeutics (PG142)
- Pressure-Reducing Support Surfaces (CG007)
- Qalsody (tofersen) (PG151)
- Rezzayo (rezafungin) (PG145)
- Rituximab (Rituxan) for Multiple Sclerosis and Myasthenia Gravis (CG055)
- Roctavian (valoctocogene roxaparvovec-rvox) (PG163)
- Sex Reassignment Surgery (Gender Affirmation Surgery) (CG017)
- Site-of-Service (Site-of-Care) (Infusion Therapy & Physician-Administered Drugs) (CG046)
- Skilled Nursing Facility Care (CG042)
- Skysona (elivaldogene autotemcel) (CG074)
- Spevigo (spesolimab-sbzo) (CG071)
- Spinal Orthoses (Back Braces) (CG051)
- Syfovre (pegcetacoplan injection) (PG150)
- Thyrogen (thyrotropin alfa) (PG140)
- Total Hip Arthroplasty (CG070)
- Total Knee Arthroplasty (CG069)
- Total Shoulder Arthroplasty (Replacement) and Reverse Total Shoulder Arthroplasty (CG076)
- Transcranial Doppler (CG035)
- Treatment and Removal of Benign Skin Lesions (CG015)
- Tzield (teplizumab-mzwv) (CG072)
- Varicose Vein Treatment (CG004)
- Varubi (rolapitant) (PG178)
- Viscosupplementation for Osteoarthritis (CG054)
- Vyjuvek (beremagene geperpavec-svdt) (PG147)
- Wearable Cardioverter Defibrillator Devices (CG019)
- Ycanth (cantharidin) (PG162)
- Yescarta (axicabtagene ciloleucel) (CG063)
- Zolgensma (onasemnogene abeparvovec-xioi) (CG061)
- Zynteglo (betibeglogene autotemcel) (CG073)
Adopted Guidelines
- American Society of Addiction Medicine (ASAM)
- American Specialty Health (ASH)
- Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII)
- Child & Adolescent Service Intensity Instrument (CASII)
- Connecticut Milliman Care Guidelines (MCG)
- Evicore
- Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS)
- Optum Behavioral Health Clinical Criteria
- Progeny
- The Early Childhood Service Intensity Instrument (ECSII)
- The World Professional Association for Transgender Health Standards of Care