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These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Prior authorization is required for Immune globulin therapy, except for the conditions listed below.

Immune globulin therapy is generally covered subject to the indications listed below, and per your plan documents.

Immunologic diagnoses

  1. Primary immunodeficiencies including:
    1. B-cell immune deficiencies including common variable immune deficiency, X-linked immunodeficiency, and Hyper-IgM syndromes
    2. Severe combined immunodeficiencies (SCID)
    3. Wiskott-Aldrich syndrome
    4. Hyperimmunglobulin E syndrome
    5. Congenital agammaglobulinemia
  2. Secondary immunodeficiencies including:
    1. Acquired hypogammagloulin conditions including B-cell chronic lymphocytic leukemia and multiple myeloma
    2. Prevention of acute graft versus host disease (GVHD) after transplantation
    3. Prevention of infection in transplant recipients (e.g., solid organ, stem cell, bone marrow)

Neurologic diagnoses

  1. Chronic inflammatory demyelinating polyneuritis (CIDP)
  2. Myasthenia gravis
  3. Lambert-Eaton myasthenic syndrome
  4. Guillain-Barre syndrome
  5. Multifocal motor neuropathy

Other diagnoses

  1. Acute and chronic immune-medicated (idiopathic) thrombocytopenia purpura (ITP)
  2. HIV-associated thrombocytopenia
  3. Kawasaki disease when used in combination with aspirin
  4. Dermatomyositis and polymyositis when first-line oral agents have failed or are contraindicated
  5. Pemphigus when corticosteroids have failed or are contraindicated

Use of immune globulin for all other diagnoses requires review for medical necessity.

Immune globulin therapy provides antibodies against a wide variety of bacterial and viral antigens. It is prepared from human blood plasma.

Some preparations have received FDA approval for subcutaneous administration. These include: Vivagloblin (not currently marketed), Hizentra, Gamunex-C.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Code Description Preparation NDC Codes
90283 Immune Globulin (IgIV) human, for intravenous use (Code price is per 500 mg) for CPT billing requirements only

Bivigam

59730650301
59730650201

Carimune NF 44206041812
44206041603
44206041706
Flebogamma 61953000301
61953000304
61953000302
61953000303
Flebogamma DIF 61953000401
61953000404
61953000402
61953000403
61953000405
61953000501
61953000502
61953000503
Gammagard S/D 00944262004
00944262002
00944262003
00944265504
00944265503
00944270002
00944270003
00944270004
00944270005
00944270006
00944270007
Gammaked 76125090001
76125090010
76125090025
76125090020
76125090050
Gammaplex 64208823401
64208823402
64208823403
Gamunex 13533064512
13533064571
13533064515
13533064524
13533064520
Gamunex-C 13533080012
13533080071
13533080015
13533080024
13533080020
Privigen 44206043710
44206043820
44206043605
90284 Immune Globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each for CPT billing requirements only Gammagard S/D 00944262004
00944262002
00944262003
00944265504
00944265503
00944270002
00944270003
00944270004
00944270005
00944270006
00944270007
Gammaked 76125090001
76125090010
76125090025
76125090020
76125090050
Gamunex-C 13533080012
13533080071
13533080015
13533080024
13533080020
Hizentra 44206045101
44206045202
44206045404
J1459 Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500mg Privigen 44206043710
44206043820
44206043605

J1460

Injection, gamma globulin, intramuscular, 1 cc

Gamastan S/D

54569582800
13533063504
13533063512
13533063513
13533063540

J1556

Injection, immune globulin (Bivigam), 500 mg

Bivigam

59730650301
59730650201

J1557 Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg Gammaplex 64208823401
64208823402
64208823403
J1559 Injection, immune globulin (Hizentra), 100 mg Hizentra 44206045101
44206045202
44206045404
J1561 Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), intravenous, non-lyophilized (e.g., liquid), 500 mg Gamunex 13533064512
13533064571
13533064515
13533064524
13533064520
Gamunex-C 13533080012
13533080071
13533080015
13533080024
13533080020
Gammaked 76125090001
76125090010
76125090025
76125090020
76125090050
J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg Carimune NF 44206041812
44206041603
44206041706
Gammagard S/D 00944262004
00944262002
00944262003
00944265504
00944265503
J1568 Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg Octagam 68209084301
67467084301
67467084305
J1569 Injection, immune globulin, (Gammagard), intravenous, non-lyophilized, (e.g., liquid), 500 mg Gammagard 00944270002
00944270005
00944270003
00944270006
00944270007
00944270004
J1572 Injection, Immune globulin, (Flebogamma/Flebogamma DIF), intravenous, non-lyophilized (e.g., liquid), 500 mg Flebogamma 61953000301
61953000304
61953000302
61953000303
Flebogamma DIF 61953000401
61953000404
61953000402
61953000403
61953000405
61953000501
61953000502
61953000503
J1575 Injection, immune globulin/hyaluronidase, (Hyqvia), 100mg immune globulin    
J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg    
ICD-10-CM Codes
Prior authorization is required for the following diagnosis codes:
CodeDescription
A18.52Tuberculous keratitis
A18.53Tuberculous chorioretinitis
A18.54Tuberculous iridocyclitis
A18.59Other tuberculosis of eye
B45.1Cerebral cryptococcosis
B60.12Conjunctivitis due to Acanthamoeba
 
B60.13Keratoconjunctivitis due to Acanthamoeba
B83.2Angiostrongyliasis due to Parastrongylus cantonensis
E08.311-E08.359Diabetes mellitus due to underlying condition with diabetic retinopathy with or without macular edema; unspecified; mild, moderate, or severe nonproliferative, or proliferative
E08.36Diabetes mellitus due to underlying condition with diabetic cataract
E08.41Diabetes mellitus due to underlying condition with diabetic mononeuropathy
 
E08.44Diabetes mellitus due to underlying condition with diabetic amyotrophy
E08.49Diabetes mellitus due to underlying condition with other diabetic neurological complication
E09.311-E09-359Drug or chemical induced diabetes mellitus with diabetic retinopathy with or without macular edema; unspecified; mild, moderate, or severe nonproliferative; proliferative
E09.36Drug or chemical induced diabetes mellitus with diabetic cataract
E09.41Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy
E09.44Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy
E09.49Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication
E10.311-E10.359Type 1 diabetes mellitus with diabetic retinopathy with or without macular edema; unspecified; mild, moderate, or severe nonproliferative; proliferative
E10.36Type 1 diabetes mellitus with diabetic cataract
E10.41Type 1 diabetes mellitus with diabetic mononeuropathy
E10.44Type 1 diabetes mellitus with diabetic amyotrophy
E10.49Type 1 diabetes mellitus with other diabetic neurological complication
E11.311-E11.359Type 2 diabetes mellitus with diabetic retinopathy with or without macular edema; unspecified; mild, moderate, or severe nonproliferative; proliferative
E11.36Type 2 diabetes mellitus with diabetic cataract
E11.41Type 2 diabetes mellitus with diabetic mononeuropathy
E11.44Type 2 diabetes mellitus with diabetic amyotrophy
E11.49Type 2 diabetes mellitus with other diabetic neurological complication
E13.21Other specified diabetes mellitus with diabetic nephropathy
E13.22Other specified diabetes mellitus with diabetic chronic kidney disease
E13.29Other specified diabetes mellitus with other diabetic kidney complication
E13.311-E13.359Other specified diabetes mellitus with diabetic retinopathy with or without macular edema; unspecified; mild, moderate, or severe nonproliferative; proliferative
E13.36Other specified diabetes mellitus with diabetic cataract
E13.41Other specified diabetes mellitus with diabetic mononeuropathy
E13.44Other specified diabetes mellitus with diabetic amyotrophy
E13.49Other specified diabetes mellitus with other diabetic neurological complication
E75.00GM2 gangliosidosis, unspecified
E75.01Sandhoff disease
E75.02Tay-Sachs disease
E75.09Other GM2 gangliosidosis
E75.10Unspecified gangliosidosis
E75.11Mucolipidosis IV
E75.19Other gangliosidosis
E75.23Krabbe disease
E75.25Metachromatic leukodystrophy
E75.29Other sphingolipidosis
E75.4Neuronal ceroid lipofuscinosis
E75.6Lipid storage disorder, unspecified
F51.04Psychophysiologic insomnia
F51.05Insomnia due to other mental disorder
F51.13Hypersomnia due to other mental disorder
F84.2Rett's syndrome
G00.0Hemophilus meningitis
 G00.1 Pneumococcal meningitis
 G00.2 Streptococcal meningitis
 G00.3 Staphylococcal meningitis
 G00.8 Other bacterial meningitis
 G00.9 Bacterial meningitis, unspecified
 G01 Meningitis in bacterial diseases classified elsewhere
 G02 Meningitis in other infectious and parasitic diseases classified elsewhere
 G03.0 Nonpyogenic meningitis
 G03.1 Chronic meningitis
 G03.8 Meningitis due to other specified causes
 G03.9 Meningitis, unspecified
 G04.00 Acute disseminated encephalitis and encephalomyelitis, unspecified
 G04.01 Postinfectious acute disseminated encephalitis and encephalomyelitis (postinfectious ADEM)
 G04.02 Postimmunization acute disseminated encephalitis, myelitis and encephalomyelitis
 G04.2 Bacterial meningoencephalitis and meningomyelitis, not elsewhere classified
 G04.30 Acute necrotizing hemorrhagic encephalopathy, unspecified
 G04.31 Postinfectious acute necrotizing hemorrhagic encephalopathy
 G04.32 Postimmunization acute necrotizing hemorrhagic encephalopathy
 G04.39 Other acute necrotizing hemorrhagic encephalopathy
 G04.81 Other encephalitis and encephalomyelitis
 G04.89 Other myelitis
 G04.90 Encephalitis and encephalomyelitis, unspecified
 G04.91 Myelitis, unspecified
G05.3  Encephalitis and encephalomyelitis in diseases classified elsewhere
 G05.4 Myelitis in diseases classified elsewhere
 G06.0 Intracranial abscess and granuloma
 G06.1 Intraspinal abscess and granuloma
G06.2Extradural and subdural abscess, unspecified
G07Intracranial and intraspinal abscess and granuloma in diseases classified elsewhere
G08Intracranial and intraspinal phlebitis and thrombophlebitis
G09Sequelae of inflammatory diseases of central nervous system
G10Huntington's disease
G11.0Congenital nonprogressive ataxia
G11.1-G11.2Early or Late-onset cerebellar ataxia
G11.4Hereditary spastic paraplegia
G11.8Other hereditary ataxias
G11.9Hereditary ataxia, unspecified
G12.0Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]
G12.1Other inherited spinal muscular atrophy
G12.20Motor neuron disease, unspecified
G12.21Amyotrophic lateral sclerosis
G12.22Progressive bulbar palsy
G12.29Other motor neuron disease
G12.8Other spinal muscular atrophies and related syndromes
G12.9Spinal muscular atrophy, unspecified
 G13.2 Systemic atrophy primarily affecting the central nervous system in myxedema
G13.8Systemic atrophy primarily affecting central nervous system in other diseases classified elsewhere
G20Parkinson's disease
G21.0Malignant neuroleptic syndrome
G21.11Neuroleptic induced parkinsonism
G21.19Other drug induced secondary parkinsonism
G21.2Secondary parkinsonism due to other external agents
G21.3Postencephalitic parkinsonism
G21.4Vascular parkinsonism
G21.8Other secondary parkinsonism
G21.9Secondary parkinsonism, unspecified
G23.0Hallervorden-Spatz disease
G23.1Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski]
G23.2Striatonigral degeneration
G23.8Other specified degenerative diseases of basal ganglia
 
G23.9Degenerative disease of basal ganglia, unspecified
G24.01Drug induced subacute dyskinesia
G24.02Drug induced acute dystonia
G24.09Other drug induced dystonia
G24.1Genetic torsion dystonia
G24.2Idiopathic nonfamilial dystonia
G24.3Spasmodic torticollis
G24.4Idiopathic orofacial dystonia
G24.8Other dystonia
G24.9Dystonia, unspecified
G25.0Essential tremor
G25.1Drug-induced tremor
G25.2Other specified forms of tremor
G25.3Myoclonus
G25.4Drug-induced chorea
G25.5Other chorea
G25.61Drug induced tics
G25.69Other tics of organic origin
G25.70Drug induced movement disorder, unspecified
G25.71Drug induced akathisia
G25.79Other drug induced movement disorders
G25.81Restless legs syndrome
G25.82Stiff-man syndrome
G25.83Benign shuddering attacks
G25.89Other specified extrapyramidal and movement disorders
G25.9Extrapyramidal and movement disorder, unspecified
G26Extrapyramidal and movement disorders in diseases classified elsewhere
G30.0–G30.9Alzheimer’s disease; early or late onset; other; unspecified
G31.01Pick’s disease
G31.09Other frontotemporal dementia
G31.1Senile degeneration of brain, not elsewhere classified
G31.2Degeneration of nervous system due to alcohol
G31.81Alpers disease
G31.82Leigh's disease
G31.83Dementia with Lewy bodies
G31.84Mild cognitive impairment, so stated
G31.85Corticobasal degeneration
G31.89Other specified degenerative diseases of nervous system
G31.9Degenerative disease of nervous system, unspecified
 G32.0 Subacute combined degeneration of spinal cord in diseases classified elsewhere
 G32.81 Cerebellar ataxia in diseases classified elsewhere
G32.89Other specified degenerative disorders of nervous system in diseases classified elsewhere
G35Multiple sclerosis
G36.0Neuromyelitis optica [Devic]
G36.1Acute and subacute hemorrhagic leukoencephalitis [Hurst]
G36.8Other specified acute disseminated demyelination
G36.9Acute disseminated demyelination, unspecified
G37.0Diffuse sclerosis of central nervous system
G37.1Central demyelination of corpus callosum
G37.2Central pontine myelinolysis
G37.3Acute transverse myelitis in demyelinating disease of central nervous system
G37.4Subacute necrotizing myelitis of central nervous system
G37.5Concentric sclerosis [Balo] of central nervous system
G37.8Other specified demyelinating diseases of central nervous system
G37.9Demyelinating disease of central nervous system, unspecified
G40.001-G40.019Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset; intractable or not intractable; with or without status epilepticus
G40.101-G40.119Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures; intractable or not intractable; with or without status epilepticus
G40.201-G40.219Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures; intractable or not intractable; with or without status epilepticus
G40.301-G40.319Generalized idiopathic epilepsy and epileptic syndromes; intractable or not intractable; with or without status epilepticus
 G40.401-G40.419 Other generalized epilepsy and epileptic syndromes; intractable or not intractable; with or without status epilepticus
 G40.501-G40.509 Epileptic seizures related to external causes, not intractable; with or without status epilepticus
 G40.801-G40.804 Other epilepsy; intractable or not intractable; with or without status epilepticus
 G40.811-G40.814 Lennox-Gastaut syndrome; intractable or not intractable; with or without status epilepticus
 G40.821-G40.824 Epileptic spasms; intractable or not intractable; with or without status epilepticus
 G40.89 Other seizures
 G40.901-G40.919 Epilepsy, unspecified; intractable or not intractable; with or without status epilepticus
 G40.A01-G40.A19 Absence epileptic syndrome; intractable or not intractable; with or without status epilepticus
 G40.B01-G40.B19 Juvenile myoclonic epilepsy; intractable or not intractable; with or without status epilepticus
 G43.001-G43.119 Migraine; with or without aura; intractable or not intractable; with or without status migrainosus
 G43.401-G43-419 Hemiplegic migraine; intractable or not intractable; with or without status migrainosus
 G43.501-G43.619 Persistent migraine aura; with or without cerebral infarction; intractable or not intractable; with or without status migrainosus
 G43.701-G43.719 Chronic migraine without aura; intractable or not intractable; with or without status migrainosus
 G43.801-G43.819 Other migraine; intractable or not intractable; with or without status migrainosus
 G43.821-G43.839 Menstrual migraine; intractable or not intractable; with or without status migrainosus
 G43.901-G43-919 Migraine, unspecified; intractable or not intractable; with or without status migrainosus
 G43.A0-G43.A1 Cyclical vomiting; intractable or not intractable
 G43.B0-G43.B1 Ophthalmoplegic migraine; intractable or not intractable
 G43.C0-G43.C1 Periodic headache syndromes in child or adult; intractable or not intractable
 G43.D0-G43.D1 Abdominal migraine; intractable or not intractable
 G44.001-G44.009 Cluster headache syndrome, unspecified; intractable or not intractable
 G44.011-G44.019 Episodic cluster headach; intractable or not intractable
 G44.021-G44.029 Chronic cluster headache; intractable or not intractable
 G44.031-G44.039 Episodic paroxysmal hemicrania; intractable or not intractable
 G44.041-G44.049 Chronic paroxysmal hemicrania; intractable or not intractable
 G44.051-G44.059 Short lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT); intractable or not intractable
 G44.091-G44.099 Other trigeminal autonomic cephalgias (TAC); intractable or not intractable
 G44.1 Vascular headache, not elsewhere classified
 G44.201-G44.209 Tension-type headache, unspecified; intractable or not intractable
 G44.211-G44.219 Episodic tension-type headache; intractable or not intractable
 G44.221-G44.229 Chronic tension-type headache; intractable or not intractable
 G44.301-G44.309 Post-traumatic headache, unspecified; intractable or not intractable
 G44.311-G44.319 Acute post-traumatic headache; intractable or not intractable
 G44.321-G44.329 Chronic post-traumatic headache; intractable or not intractable
G44.40-G4.41Drug-induced headache, not elsewhere classified; intractable or not intractable
G44.51Hemicrania continua
G44.52New daily persistent headache (NDPH)
G44.53Primary thunderclap headache
G44.59Other complicated headache syndrome
G44.81Hypnic headache
G44.82Headache associated with sexual activity
G44.83Primary cough headache
G44.84Primary exertional headache
G44.85Primary stabbing headache
G44.89Other headache syndrome
G45.3Amaurosis fugax
G47.00Insomnia, unspecified
G47.01Insomnia due to medical condition
G47.09Other insomnia
G47.10Hypersomnia, unspecified
G47.11-G47.12Idiopathic hypersomnia; with or without long sleep time
G47.13Recurrent hypersomnia
G47.14Hypersomnia due to medical condition
G47.19Other hypersomnia
G47.20-G47.29Circadian rhythm sleep disorder; unspecified type; delayed or advanced sleep phase type; irregular sleep wake typed; free running type; jet lag type; shift work type; in conditions classified elsewhere; or other circadian rhythm sleep disorder
G47.30Sleep apnea, unspecified
G47.31Primary central sleep apnea
G47.32High altitude periodic breathing
G47.33Obstructive sleep apnea (adult) (pediatric)
G47.34Idiopathic sleep related nonobstructive alveolar hypoventilation
G47.39Other sleep apnea
G47.411-G47.419Narcolepsy; with or without cataplexy
G47.421-G47.429Narcolepsy in conditions classified elsewhere; with or without cataplexy
G47.50Parasomnia, unspecified
G47.51Confusional arousals
G47.52REM sleep behavior disorder
G47.53Recurrent isolated sleep paralysis
G47.54Parasomnia in conditions classified elsewhere
G47.59Other parasomnia
G47.61Periodic limb movement disorder
G47.62Sleep related leg cramps
G47.63Sleep related bruxism
G47.69Other sleep related movement disorders
G47.8Other sleep disorders
G50.0Trigeminal neuralgia
G50.1Atypical facial pain
G50.8Other disorders of trigeminal nerve
G50.9Disorder of trigeminal nerve, unspecified
G51.0Bell's palsy
G51.1Geniculate ganglionitis
G51.2Melkersson's syndrome
G51.3Clonic hemifacial spasm
G51.4Facial myokymia
G51.8Other disorders of facial nerve
G51.9Disorder of facial nerve, unspecified
G52.0Disorders of olfactory nerve
G52.1Disorders of glossopharyngeal nerve
G52.2Disorders of vagus nerve
G52.3Disorders of hypoglossal nerve
G52.7Disorders of multiple cranial nerves
G52.8Disorders of other specified cranial nerves
G52.9Cranial nerve disorder, unspecified
G53Cranial nerve disorders in diseases classified elsewhere
G54.0Brachial plexus disorders
G54.1Lumbosacral plexus disorders
G54.2Cervical root disorders, not elsewhere classified
G54.3Thoracic root disorders, not elsewhere classified
G54.4Lumbosacral root disorders, not elsewhere classified
G54.5Neuralgic amyotrophy
G54.6-G54.7Phantom limb syndrome; with or without pain
G54.8Other nerve root and plexus disorders
G54.9Nerve root and plexus disorder, unspecified
G55Nerve root and plexus compressions in diseases classified elsewhere
G56.00-G56.02Carpal tunnel syndrome; unspecified; right upper limb; left upper limb
G56.10-G56.12Other lesions of median nerve; unspecified; right upper limb; left upper limb
G56.20-G56.22Lesion of ulnar nerve; unspecified; right upper limb; left upper limb
G56.30-G56.32Lesion of radial nerve; unspecified; right upper limb; left upper limb
G56.40-G56.42Causalgia; unspecified; right upper limb; left upper limb
G56.80-G56.82Other specified mononeuropathies; unspecified; right upper limb; left upper limb
 G56.90-G56.92 Unspecified mononeuropathy; unspecified; right upper limb; left upper limb
 G57.00-G57.02 Lesion of sciatic nerve; unspecified; right lower limb; left lower limb
 G57.10-G57.12 Meralgia paresthetica; unspecified; right lower limb; left lower limb
 G57.20-G57.22 Lesion of femoral nerve; unspecified; right lower limb; left lower limb
 G57.30-G57.32 Lesion of lateral popliteal nerve; unspecified; right lower limb; left lower limb
 G57.40-G57.42 Lesion of medial popliteal nerve; unspecified; right lower limb; left lower limb
G57.50-G57.52 Tarsal tunnel syndrome; unspecified; right lower limb; left lower limb
 G57.60-G57.62 Lesion of plantar nerve; unspecified; right lower limb; left lower limb
 G57.70-G57-72 Causalgia; unspecified; right lower limb; left lower limb
 G57.80-G57.82 Other specified mononeuropathies; unspecified; right lower limb; left lower limb
 G57.90-G57.92 Unspecified mononeuropathy; unspecified; right lower limb; left lower limb
 G58.0 Intercostal neuropathy
 G58.7 Mononeuritis multiplex
 G58.8 Other specified mononeuropathies
 G58.9 Mononeuropathy, unspecified
G59Mononeuropathy in diseases classified elsewhere
G60.0Hereditary motor and sensory neuropathy
G60.1Refsum's disease
G60.2Neuropathy in association with hereditary ataxia
G60.3Idiopathic progressive neuropathy
G60.8Other hereditary and idiopathic neuropathies
 G60.9 Hereditary and idiopathic neuropathy, unspecified
G80.0Spastic quadriplegic cerebral palsy
G80.1Spastic diplegic cerebral palsy
G80.2Spastic hemiplegic cerebral palsy
G80.3Athetoid cerebral palsy
 
G80.4Ataxic cerebral palsy
G80.8Other cerebral palsy
G80.9Cerebral palsy, unspecified

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References

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This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 11/14/2011 - Date of origin
  • 1/01/2012 - Effective date
Reviews & revisions
  • 10/1/2015
Policy number
  • I009-02

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