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Coverage criteria policies

HealthPartners has Medical Policies that contain coverage criteria that describe how we make coverage decisions for certain health care 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 35 of 518 policies
Policy name Policy category Product Prior authorization required
Abatacept (Orencia®) - Effective 1/1/2017PharmacyMinnesota
Wisconsin
MHCP
HealthPartners Care
Iowa
Yes
Abatacept (Orencia®) - Retire 12/31/2016PharmacyMinnesota
Wisconsin
MHCP
HealthPartners Care
Iowa
Yes
Access to outpatient behavioral health servicesBehavioral HealthMHCP
HealthPartners Care
Minnesota
Yes
Actinic keratoses treatmentMedical ServicesMHCP
HealthPartners Care
Minnesota
Wisconsin
Iowa
No
AcupunctureAncillary ServicesMHCP
HealthPartners Care
Iowa
Minnesota
No
Acupuncture – WisconsinAncillary ServicesWisconsinNo
Ado-trastuzumab (Kadcyla®)PharmacyMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Advanced drug therapy for pulmonary hypertension: epoprostenol (generic, Flolan® and Veletri®), treprostinil (Remodulin® and Tyvaso®), iloprost (Ventavis®) and sildenafil injection (Revatio®)PharmacyMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Agalsidase beta (Fabrazyme®) - Effective 1/1/2017PharmacyMinnesota
Wisconsin
MHCP
HealthPartners Care
Iowa
Yes
Air compressorEquipment/SuppliesMinnesota
Wisconsin
MHCP
HealthPartners Care
Iowa
No
Airway clearance system / chest compression generator systemEquipment/SuppliesMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Alemtuzumab (Lemtrada™)PharmacyMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Allergy testing immunotherapyMedical ServicesHealthPartners Care
Iowa
Minnesota
Wisconsin
MHCP
No
Alopecia areata treatmentMedical ServicesMHCP
HealthPartners 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®) - Effective 1/1/2017PharmacyMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: Alpha-1 Proteinase Inhibitor (Aralast NP®, Glassia®, Prolastin®-C®, and Zemaira®) - Retire 12/31/2016PharmacyMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Ambu bagEquipment/SuppliesMinnesota
Wisconsin
MHCP
HealthPartners Care
Iowa
No
Ambulance & medical transportationAncillary ServicesIowa
Minnesota
Wisconsin
Yes
Ambulance Transportation Services - Minnesota Health Care ProgramsAncillary ServicesMHCP
HealthPartners Care
Yes
Anesthesia services for routine gastrointestinal endoscopic proceduresAdministrativeMinnesota
Iowa
MHCP
HealthPartners Care
Wisconsin
No
Ankle replacement surgerySurgeryMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Anti-nausea wristbandEquipment/SuppliesMinnesota
Wisconsin
MHCP
HealthPartners Care
Iowa
No
Apnea monitorEquipment/SuppliesMinnesota
Wisconsin
MHCP
HealthPartners Care
Iowa
No
Aqua K pad and pumpEquipment/SuppliesMinnesota
Wisconsin
MHCP
HealthPartners Care
Iowa
No
Artificial insemination (AI) or intra-uterine insemination (IUI)Medical ServicesIowa
Minnesota
Wisconsin
No
Artificial intervertebral disc replacement - cervicalMedical Services
Spine
Surgery
MHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Artificial intervertebral disc replacement - lumbarSpine
Surgery
Medical Services
MHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
No
Asparaginase Erwinia chrysanthemi (Erwinaze®)PharmacyMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Atezolizumab (Tecentriq®)PharmacyMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
Yes
Augmentative communication deviceEquipment/SuppliesIowa
Minnesota
Wisconsin
No
Augmentative communication device – Minnesota Health Care ProgramsEquipment/SuppliesMHCP
HealthPartners Care
No
Authorized care outside the service areaOtherMinnesotaYes
Autologous chondrocyte implantation (ACI)Medical ServicesMHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
No
Autologous platelet rich plasma (PRP) injectionsInvestigational
Medical Services
MHCP
HealthPartners Care
Iowa
Minnesota
Wisconsin
No
Viewing 35 of 518 policies
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