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.
Upcoming Policy Changes
- 2025 Q1 Pharmacy & Therapeutics Summary of Changes
- 2025 Q1 Clinical Advisory Subcommittee (CAS) Summary of Changes
- 2025 Q2 Clinical Advisory Subcommittee (CAS) Summary of Changes
- 2025 Q2 (April & May) P&T Summary of Changes
- 2025 Q2 (June) P&T Summary of Changes
- Effective 8/1/2025
- Antineoplastic and Immunomodulating Agents - Tocilizumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG108, Ver. 2)
- Effective 9/1/2025
- Acupuncture (CG013, Ver. 11)
- Bariatric Surgery and Revision of Bariatric Surgery (Adolescents/ Ages 13 - 17) (CG009, Ver. 11)
- Bariatric Surgery and Revision of Bariatric Surgery (Adults) (CG008, Ver. 11)
- Diagnosis and Treatment of Infertility (CG016, Ver. 13)
- Home Care - Home Health Aides (HHA) (CG022, Ver. 11)
- Home Care - Physical Therapy (PT) and Occupational Therapy (OT) (CG021, Ver. 11)
- Home Care - Speech Language Pathology (SLP) Services (CG023, Ver. 11)
- Home Care - Skilled Nursing Care (RN, LVN/LPN) (CG020, Ver. 11)
- Intraoperative Neuromonitoring (CG045, Ver. 9)
- Medical Nutrition Therapy (Dietary Evaluation & Counseling) (CG010, Ver. 11)
- Outpatient Physical Therapy (PT) and Occupational Therapy (OT) (CG044, Ver. 9)
- Skilled Nursing Facility Care (CG042, Ver. 11)
- Effective 10/1/2025
- Briumvi (ublituximab) (PG134, Ver. 5)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 3)
- Collagenase Ointment (Santyl) (PG141, Ver. 3)
- Durysta (bimatoprost intracameral implant) (CG116, Ver. 3)
- Kebilidi (eladocagene exuparvovec-tneq) (PG259, Ver. 1)
- Lemtrada (Alemtuzumab) (PG226, Ver. 2)
- Lenmeldy (atidarsagene autotemcel) (CG117, Ver. 2)
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235, Ver. 4)
- Tevimbra (tislelizumab) (PG210, Ver. 2)
- Effective 11/1/2025
- Antineoplastics - Cyclophosphamide Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Policy (CG120, Ver. 1)
- Antineoplastics - Pemetrexed Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG105, Ver. 3)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 7)
- Ambulatory Cardiac Event Monitoring (CG032, Ver. 11)
- Autonomic Testing (CG026, Ver. 11)
- Balloon Ostial Dilation (CG018, Ver. 11)
- Benign Prostatic Hyperplasia Procedures (CG031, Ver. 11)
- Breast Imaging (CG027, Ver. 11)
- Breast Procedures (CG036, Ver. 12)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 5)
- (Commercial) Preferred Physician-Administered Specialty Drugs (CG052, Ver. 32)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098, Ver. 4)
- Concomitant use of biologics and tsDMARDs (CG064, Ver. 6)
- Deep Brain Stimulation (DBS) and Responsive Neurostimulation (RNS) (CG050, Ver. 9)
- Dupixent (dupilumab) (PG026, Ver. 14)
- Experimental or Investigational Services, Products, Drugs, and Biologicals (CG012, Ver. 12)
- Furoscix (furosemide) 8mg/1mL Solution for injection [On-Body Infusor] (PG132, Ver. 5)
- Glaucoma Surgery (CG034, Ver. 11)
- Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094, Ver. 4)
- Hyperbaric Oxygen Therapy (CG014, Ver. 11)
- Hypoglossal Nerve Stimulation (CG065, Ver. 6)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107, Ver. 3)
- Injectable Iron Supplements (PG196, Ver. 4)
- Lenmeldy (atidarsagene autotemcel) (CG117, Ver. 3)
- Lyfgenia (lovotibeglogene autotemcel) (CG114, Ver. 3)
- Mitoxantrone (Novantrone) (PG126, Ver. 4)
- Multiple Sclerosis Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG096, Ver. 4)
- Pain Management: Epidural Steroid Injections, Selective Nerve Root Blocks (SNRB), and Intradiscal Steroid Injections (CG048, Ver. 9)
- Pain Management: Facet Joint Injections/Medial Branch Blocks and Radiofrequency Facet Denervation (CG047, Ver. 9)
- PiaSky (crovalimab-akkz) (PG262, Ver. 1)
- Qalsody (tofersen) (PG151, Ver. 4)
- Quantity Limit Exception Criteria (PG200, Ver. 3)
- Sex Reassignment Surgery (Gender Affirmation Surgery) and Non-Surgical Services (CG017, Ver. 15)
- Thyrogen (thyrotropin alfa) (PG140, Ver. 3)
- Transcranial Doppler (CG035, Ver. 11)
- Viscosupplementation for Osteoarthtiris (CG054, Ver. 9)
- Zolgensma (onasemnogene abeparvovec-xioi) (CG061, Ver. 7)
Medical Guidelines
- Acupuncture (CG013)
- Adakveo (crizanlizumab) (PG193, Ver. 2)
- Aduhelm (aducanumab-avwa) (PG139)
- Allergy Immunotherapy (CG059)
- Ambulatory Cardiac Event Monitoring (CG032)
- Ambulance Services (CG057)
- Anesthesia and Sedation in Endoscopy (CG041)
- Anti-migraine Agents/ Calcitonin Gene-Related Peptide (CGRP) Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008)
- Approved and Accepted Off-label Medical Necessity Criteria for Products, Drugs and Biologicals (PG136, Ver. 3)
- Autonomic Testing (CG026)
- Balloon Ostial Dilation (CG018)
- Bariatric Surgery (Adults) (CG008)
- Bariatric Surgery (Adolescents) (CG009)
- Benlysta (belimumab) (PG014)
- Beqvez (fidanacogene elaparvovec) (CG118)
- Beyfortus (nirsevimab-alip) (PG180)
- Bioengineered Skin and Soft Tissue Substitutes (CG030)
- Botulinum Toxin (CG033, Ver. 15)
- BPH Treatment (CG031)
- Breast Imaging (CG027)
- Breast Procedures (CG036)
- Breast Pumps - Manual and Electric (CG002)
- Briumvi (ublituximab) (PG134)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 2)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) CAR T-cell (CG067)
- Collagenase Ointment (Santyl) (PG141)
- Colorectal Cancer Screening (CG024)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 31)
- PY25 Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (effective thru 12/31/2025)
- Agents for Amyloidosis-Associated Polyneuropathy - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG109, Ver. 1)
- Antiemetics - Substance P/Neurokinin 1 (NK1) Antagonist (i.e., Fosaprepitant Products) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG103, Ver. 1)
- Antineoplastics - Bendamustine Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG102, Ver. 1)
- Antineoplastics - Bevacizumab for Cancer Indications - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG083, Ver. 3)
- Antineoplastics - Gemcitabine Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG104, Ver. 2)
- Antineoplastics - HER2-Targeted Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG101, Ver. 1)
- Antineoplastics - Pemetrexed Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG105, Ver. 2)
- Antineoplastics - Proteosome Inhibitors (i.e., bortezomib, carfilzomib) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG106, Ver. 1)
- Antineoplastics - Trastuzumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG082, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 6)
- Antineoplastic and Immunomodulating Agents - Infliximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG087, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Rituximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG081, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Tocilizumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG108, Ver. 1)
- Biologics for Chronic Respiratory and Allergic Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG100, Ver. 3)
- Botulinum Toxins - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG088, Ver. 3)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098, Ver. 3)
- Erythropoiesis-Stimulating Agent (ESA) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG084, Ver. 2)
- Factor IX Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG089, Ver. 2)
- Factor VIII (Long-Acting) Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG090, Ver. 2)
- Factor VIII Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG091, Ver. 2)
- Follicle Stimulating Hormone (FSH) Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG092, Ver. 2)
- Gaucher's Disease Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG093, Ver. 2)
- Gonadotropin-Releasing Hormone Agonists for Prostate Cancer - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG085, Ver. 2)
- Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094, Ver. 3)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107, Ver. 2)
- Long-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG079, Ver. 2)
- Long-Acting Reversible Contraceptives - Medical Benefit Preferred Physician- Administered Drug Exceptions Criteria (CG095, Ver. 3)
- Multiple Sclerosis Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG096, Ver. 3)
- Prostacyclin Analogs/Receptor Agonists for Pulmonary Hypertension (PAH) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG097, Ver. 2)
- Short-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG080, Ver. 3)
- Somatostatin Analogs - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG078, Ver. 4)
- Vascular Endothelial Growth Factor (VEGF) Inhibitor Ophthalmic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG099, Ver. 4)
- Concomitant (Concurrent) use of Biologics (Biologic Response Modifiers Therapies) and targeted synthetic Disease-Modifying Antirheumatic Drugs (tsDMARDs) (CG064)
- Contact Lenses and Eyeglasses (CG039)
- COVID-19 Antibody Testing (CG077)
- Deep Brain Stimulation and Responsive Neurostimulation (CG050)
- Diabetes Equipment and Supplies (CG028)
- Dupixent (dupilumab) (PG026)
- Durysta (bimatoprost intracameral implant) (CG116)
- Elevidys (delandistrogene moxeparvovec-rokl) (PG160)
- Erectile Dysfunction (CG037)
- Enteral and Oral Liquid Nutritional Supplements (CG011)
- Experimental and Investigational Services (CG012)
- Furoscix (furosemide) 8mg/1mL Solution for injection [On-Body Infusor] (PG132, Ver. 4)
- Glaucoma Surgery (CG034)
- Growth Hormones (PG049)
- 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)
- iDose TR (travoprost intracameral implant) (CG115)
- Ilaris (canakinumab) (PG185)
- Immune Globulin Weight-Based Dosing Criteria (PG256, Ver. 1)
- Infertility Injectable Agents (PG119)
- Infertility Treatment (CG016)
- Injectable Iron Supplements (PG196)
- Insulin Delivery Systems and Continuous Glucose Monitoring (CG029, Ver. 15)
- Intraoperative Neuromonitoring (CG045)
- Ilumya (tildrakizumab-asmn) (CG053, Ver. 8)
- Izervay (avancincaptad pegol) (PG168, Ver. 3)
- Kisunla (donanemab-azbt) (PG238)
- Kymriah (tisagenlecleucel) (CG058)
- Lamzede (velmanase alfa-tycv) (PG146)
- Lantidra (donislecel-jujn) (PG167)
- Lemtrada (Alemtuzumab) (PG226)
- Lenmeldy (atidarsagene autotemcel) (CG117)
- Leqembi (lecanemab-irmb) (PG138)
- Long-Term Acute Care Hospital (LTACH) (CG062)
- Luxturna (voretigene neparvovec-rzyl) (CG060)
- Lyfgenia (lovotibeglogene autotemcel) (CG114)
- Medical Nutrition Therapy (CG010)
- Mitoxantrone (Novantrone) (PG126)
- NexoBrid (anacaulase-bcdb) (CG112)
- Negative Pressure Wound Therapy and Negative Pressure Infusion Therapy (CG068)
- Niktimvo (axatilimab) (PG252)
- Noninvasive Positive Pressure Ventilation (CG003)
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235)
- 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)
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] (PG245)
- Pedmark (sodium thiosulfate) (PG133)
- Pneumatic Compression Pumps (CG049)
- Prenatal Testing (CG043)
- Prescription Digital Therapeutics (PG142)
- Pressure-Reducing Support Surfaces (CG007)
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors (PG068)
- Qalsody (tofersen) (PG151)
- Rebyota (fecal microbiota, live - jslm) (PG240)
- Rezzayo (rezafungin) (PG145)
- Roctavian (valoctocogene roxaparvovec-rvox) (PG163)
- Rystiggo (rozanolixizumab-noli) (PG190, Ver. 2)
- 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)
- Soliris (eculizumab) (PG188, Ver. 2)
- Spevigo (spesolimab-sbzo) (CG071)
- Spinal Orthoses (Back Braces) (CG051)
- Spravato (esketamine) (PG257, Ver. 1)
- Syfovre (pegcetacoplan injection) (PG150)
- Tevimbra (tislelizumab) (PG210)
- 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)
- Tremfya (guselkumab) (PG250)
- Tysabri (natalizumab) (PG195)
- Tzield (teplizumab-mzwv) (CG072)
- Ultomiris (ravulizumab-cwvz) (PG189)
- Varicose Vein Treatment (CG004)
- Varubi (rolapitant) (PG178)
- Viscosupplementation for Osteoarthritis (CG054)
- Vyjuvek (beremagene geperpavec-svdt) (PG147, Ver. 3)
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa-fcab) (PG191)
- Wearable Cardioverter Defibrillator Devices (CG019)
- Winrevair (sotatercept-csrk) (PG207, Ver. 2)
- Ycanth (cantharidin) (PG162, Ver. 3)
- 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)
- MCG Guidelines
- 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