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HealthPartners

Coverage criteria policies

Medically Necessary / Medical Necessity

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

Administrative Process

Does not require prior approval.

Coverage

Preventive services, diagnostic testing and medical treatment which are medically appropriate to the member's physical or mental diagnosis for an injury or illness are covered as per the indications listed below.

Medical necessity is the primary criterion that is considered in determining whether a health care service is eligible for coverage for a specific benefit under a member contact. Other definitions that are also used in determining coverage of eligible services are "custodial", "rehabilitative", "reconstructive", "investigative", and "cosmetic" as well as explicit contract exclusions. When more than one definition applies to a service, the most restrictive applies, and specific exclusions take precedence over general benefit description. (e.g., medically necessary, custodial care is not covered).

The Health Plan Medical Director or designee makes determinations of medical necessity. Provision or authorization of a health care service by a network provider does not establish coverage for that service.

Indications that are covered

  1. Care must be within clinically accepted medical services and practice parameters of the general medical community; and
  2. Care must be an appropriate type of service delivered at an appropriate frequency and level of care, and in an appropriate setting for the member's condition; and
  3. It must meet criteria to restore health or maintain the members health; or
  4. Prevent the deterioration of the member's condition; or
  5. It must prevent the reasonably likely onset of a health problem or detect an incipient problem.

If a particular service meets the criteria listed above, except that it fails the appropriate type of service criterion , HealthPartners may cover up to the cost of an eligible appropriate service that would have been sufficient to safely and adequately diagnose or treat the member's medical or mental health condition. Such cases are determined on a case by case basis by our Medical Director or designee.

Indications that are not covered

  1. Care which is maintenance, non-rehabilitative or custodial care or required for reasons of convenience of the member, the family or the physician.
  2. Care which is primarily for education, comfort, appearance, recreation or vocational reasons is excluded under the member contract.
  3. Care specifically excluded by a member's contract.

Definitions

Medically necessary care is diagnostic testing and medical treatment which is medically appropriate to the member's physical or mental diagnosis for an injury or illness, and preventive services covered in the member’s contract.  Medically necessary care must meet the following criteria: 

  1. It meets clinically accepted medical services and practice parameters of the general medical community; and
  2. It is an appropriate type of service delivered at an appropriate frequency and level of care, and in an appropriate setting for the member's condition; and
  3. It restores or maintains health; or
  4. It prevents deterioration of the member's condition; or
  5. It prevents the reasonably likely onset of a health problem or detects an incipient problem. 

Products

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

  • 04/30/1994 - Date of origin
  • 08/14/2017 - Effective date
Review date
  • 02/2017
Revision date
  • 08/09/2017

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