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Coverage criteria policies

HealthPartners has Medical Policies that contain coverage criteria that describe how we make coverage decisions for certain healthcare services and items. Which coverage criteria apply to your plan depends upon the state in which the plan was purchased, which is not necessarily your state of residence. For a customized experience, log on to myHealthPartners. For questions, call the Member Services number on the back of your member identification card.

The information regarding coverage guidelines is regularly updated and is subject to change without notice. Read moreā€¦

MN and WI Medicare plans

For Medicare National Coverage Determinations (NCDs) and/or Medicare Local Coverage Determinations (LCDs), please consult the Centers for Medicare and Medicaid Services or National Government Services.

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

Viewing 38 of 523 policies
Policy name Policy category Product Prior authorization required
Abatacept (Orencia®)PharmacyHealthPartners Care
Minnesota
Wisconsin
Iowa
Yes
Abdominoplasty/panniculectomySurgeryMinnesota
HealthPartners Care
Wisconsin
Iowa
Yes
Access to outpatient behavioral health servicesBehavioral HealthMinnesota
HealthPartners Care
Yes
Access to outpatient behavioral health services - Iowa & WisconsinBehavioral HealthIowa
Wisconsin
Yes
ActigraphyMedical Services
Investigational
HealthPartners Care
Minnesota
Wisconsin
Iowa
No
Actinic keratoses treatmentMedical ServicesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
AcupunctureAncillary ServicesMinnesota
HealthPartners Care
Iowa
Yes
Acupuncture – WisconsinAncillary ServicesWisconsinNo
Ado-trastuzumab (Kadcyla®)PharmacyMinnesota
Iowa
Yes
AdoptionOtherHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Advanced drug therapy for pulmonary hypertension: epoprostenol (generic, Flolan® and Veletri®), treprostinil (Remodulin® & Tyvaso®), iloprost (Ventavis®) and sildenafil injection (Revatio®)PharmacyHealthPartners Care
Minnesota
Wisconsin
Iowa
Yes
Air compressorEquipment/SuppliesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Air-fluidized specialty bed (group III)Equipment/SuppliesHealthPartners Care
Minnesota
Wisconsin
Iowa
Yes
Airway clearance system/chest compression generator systemEquipment/SuppliesHealthPartners Care
Minnesota
Wisconsin
Iowa
Yes
Alefacept (Amevive®)PharmacyHealthPartners Care
Minnesota
Wisconsin
Iowa
Yes
Allergy testing immunotherapyMedical ServicesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Allograft transplant for orthopedic procedures of the knee (e.g., DeNovo®NT)Investigational
Medical Services
Surgery
Minnesota
HealthPartners Care
Wisconsin
Iowa
Yes
Alopecia areata treatmentMedical ServicesHealthPartners Care
Minnesota
Wisconsin
No
Alopecia areata treatment - IowaMedical ServicesIowaNo
Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: alpha-1 proteinase inhibitor (Aralast/NP, Glassia®, Prolastin/C and Zemaira®)PharmacyHealthPartners Care
Minnesota
Wisconsin
Iowa
Yes
Ambu bagEquipment/SuppliesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Ambulance & medical transportationAncillary ServicesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Ankle replacement surgerySurgeryHealthPartners Care
Minnesota
Wisconsin
Iowa
Yes
Anti-nausea wristbandEquipment/SuppliesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Apnea monitorEquipment/SuppliesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Aqua K pad and pumpEquipment/SuppliesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Arch support – HealthPartners CareEquipment/SuppliesHealthPartners CareNo
Artificial Intervertebral Disc Replacement - CervicalSurgery
Spine
Medical Services
Minnesota
HealthPartners Care
Wisconsin
Iowa
Yes
Artificial insemination (AI) or intra-uterine insemination (IUI)Medical ServicesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Artificial intervertebral disc replacement - lumbarInvestigational
Spine
HealthPartners Care
Minnesota
Wisconsin
Iowa
No
Asparaginase Erwinia chrysanthemi (Erwinaze®)PharmacyMinnesota
HealthPartners Care
Wisconsin
Iowa
Yes
Augmentative communication deviceEquipment/SuppliesMinnesota
Wisconsin
Iowa
No
Augmentative communication device – HealthPartners CareEquipment/SuppliesHealthPartners CareNo
Authorized care outside the service areaOtherMinnesotaYes
Autologous bone marrow grafting (ABMG) for osteonecrosisSurgeryHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Autologous chondrocyte implantation (ACI)Medical ServicesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Autologus platelet rich plasma (PRP) injectionsMedical Services
Investigational
HealthPartners Care
Minnesota
Wisconsin
Iowa
No
AutopsyAncillary ServicesHealthPartners Care
Minnesota
Wisconsin
Iowa
No
Viewing 38 of 523 policies
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