Medical
Learn the clinical criteria we use to make medical necessity determinations for coverage of these medical and surgical services rendered to our members.
These criteria are developed with input from practicing clinicians in relevant specialties and are based on clinical evidence. We review the criteria annually.
Please refer to our medical policies and payment policies (
) for information about other services not listed here.
Ambulance
Air Ambulance (excluding the Federal Employee Program)
- Air Ambulance (all Federal Employee Program plans)
- Ground Ambulance
Outpatient High Technology Diagnostic Imaging (only for the Federal Employee Program plan, FEP Blue Focus)
Outpatient Pediatric Pain Rehabilitation Centers
PT/OT Medical Necessity - Vestibular Rehabilitation
Skilled Nursing Facility (Federal Employee Program Standard Option)
