Deep, sourced explainers on how insurers actually decide what they'll cover — the real 2026 criteria, compared side by side by insurer, digested from each company's own published policy.
The same patient, same diagnosis, same test results — approved by one insurer, denied by another. We compared the actual 2026 criteria across eight procedures and found gaps wide enough to change the outcome: an 8-point BMI gap for a sleep-apnea implant, a 50% difference in breast-reduction thresholds, a three-year age gap for depression treatment.
GLP-1 drugs and bariatric surgery, with the real BMI thresholds compared across Cigna, Aetna, UHC, Anthem and Medicare.
Read the guide →The AHI and BMI windows that decide it — and why Anthem stops at BMI 32 while Cigna, Aetna and UnitedHealthcare go to 40.
Read the guide →Why it's the X-ray (Kellgren-Lawrence Grade 3–4), not the pain, that decides — plus the conservative-care trial each insurer wants.
Read the guide →The first gate isn't your BMI — it's whether your plan covers anti-obesity drugs at all, and the supervised-program trial that differs by insurer.
Read the guide →There's no fixed number — insurers scale the gram requirement to your body size with the Schnur scale, and Aetna's table is stricter than the rest.
Read the guide →Cigna covers gastric sleeve, bypass, and lap band at a lower BMI bar than most (35, or 30 with a condition) — but gastric balloons generally aren't covered.
Read the guide →UHC covers the standard bariatric procedures at BMI 40 (or 35 with a condition) — plus a supervised program and, on many plans, a designated facility.
Read the guide →BMI 40 (or 35 with a condition), plus the evaluations and supervised program Aetna's CPB 0157 requires.
Read the guide →BMI 40 (or 35 with a condition) and documented conservative therapy under Anthem's CG-SURG-83.
Read the guide →Medicare covers the surgery (unlike the drugs) at BMI 35 with a condition and failed prior treatment — CMS NCD 100.1.
Read the guide →Why eczema drugs like Dupixent, Rinvoq and Cibinqo get denied — the three fixable gates (severity, topical step therapy, specialist) — and how to win the appeal.
Read the guide →Not through standard Part D for weight loss — but the new $50 GLP-1 Bridge and the heart-disease path are two ways in.
Read the guide →Does Medicare cover a specific drug? Ozempic · Mounjaro · Zepbound · Trulicity · Rybelsus · Jardiance · Farxiga · Januvia · Eliquis · Xarelto · Entresto · Trelegy · Lipitor · Biktarvy · Dupixent · Humira
The tablet is covered but the capsule isn't; the 50 mg is blocked for a 100 mg you split. Why these petty denials happen and how to dodge them.
Read the guide →The handful of fixable reasons most prior-auth requests are denied — and how to get ahead of each one.
Read the guide →After a job change, divorce, or aging off a parent's plan, your meds and procedures may be covered differently — and prior auths don't transfer.
Read the guide →It's almost always timing and documentation, not the scan — the red-flag fast track versus the conservative-care path.
Read the guide →Skilled need, a plan of care, and functional progress — what keeps therapy covered, and the maintenance trap that ends it.
Read the guide →When it counts as reconstructive rather than cosmetic — symptoms, conservative care, and the tissue threshold.
Read the guide →There's a provider side too: WillItClear — a prior-auth note auditor and readiness checklist for coordinators that flag documentation gaps before you submit. Checked against eviCore, Carelon, and Medicare criteria; runs entirely in your browser. $100/month value, free in beta.
The guides explain the rules; the free tools check where you stand against your insurer's real criteria in about two minutes — across weight & metabolic, sleep apnea, imaging, orthopedic, therapy, cosmetic, mental health and more.