Medical Policy UpdatesCoOportunity 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 more…
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
| Policy name | Policy category | Product | Prior authorization required |
|---|---|---|---|
| Sacral nerve stimulation for fecal incontinence | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Sacroiliac joint pain treatment procedures | Medical Services Spine | CoOportunity Health Iowa Nebraska | Yes |
| Saline or sterile water | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Scales | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Scar revision/keloids | Surgery | CoOportunity Health Iowa Nebraska | No |
| Seating support orthosis (SSO) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Selective nerve root block for diagnoses of chronic low back pain with radiculopathy | Medical Services Spine | CoOportunity Health Iowa Nebraska | Yes |
| Sex therapy | Behavioral Health | CoOportunity Health Iowa Nebraska | Yes |
| Sexual dysfunction - medical treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Shoes | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Short term treatment of acute psychiatric illness criteria | Behavioral Health | CoOportunity Health Iowa Nebraska | No |
| Shoulder resurfacing | Investigational Surgery Medical Services | CoOportunity Health Iowa Nebraska | No |
| Silicone gel sheeting | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Siltuximab (Sylvant®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Sipuleucel-T (Provenge®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Sitz baths | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Skilled nursing facility | Ancillary Services | CoOportunity Health Iowa Nebraska | Yes |
| Sleep study (polysomnogram) | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Snoring treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Spacers | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Specialty mattress replacement/overlay (group I) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Speech therapy – habilitative | Ancillary Services | CoOportunity Health Iowa Nebraska | Yes |
| Speech therapy – rehabilitative | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Spinal cord stimulator (SCS) | Surgery Spine | CoOportunity Health Iowa Nebraska | Yes |
| Spinal fusion – lumbar | Surgery Spine | CoOportunity Health Iowa Nebraska | Yes |
| Spinal laminectomy | Medical Services Spine Surgery | CoOportunity Health Iowa Nebraska | No |
| Spinal unloading devices | Equipment/Supplies Spine | CoOportunity Health Iowa Nebraska | No |
| Splints – durable (long term) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Splints – supply (short term) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Standing frame/stander | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Stereotactic radiosurgery | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Sterilization | Medical Services Preventive | CoOportunity Health Iowa Nebraska | No |
| Strabismus surgery | Surgery | CoOportunity Health Iowa Nebraska | No |
| Sublingual immunotherapy (SLIT) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Suction machine and catheter | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Sun tanning booths | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Sympathectomy (thoracic) for the treatment of primary hyperhidrosis | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Synagis (palivizumab) injections for respiratory syncytial virus (RSV) prophylaxis - Effective 11/1/14 | Medical Services Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
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