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HealthPartners

Coverage criteria policies

Investigational services

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

Services that meet the definition of investigational are not eligible for coverage. HealthPartners has established a list of non-covered investigational services - see the Investigational Services: List of Noncovered Services policy.

Any new or potentially investigative service or device not included in the Investigative List of Noncovered Services requires prior authorization.

Coverage

We will consider the following categories of reliable evidence, none of which shall be determinative by itself:

  1. Whether there is final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); if the drug or device or medical treatment or procedure is under study or if further studies are needed to determine its maximum tolerated dose, toxicity, safety, or efficacy as compared to the standard means of treatment or diagnosis; and
  2. Whether there are consensus opinions or recommendations in relevant scientific and medical literature, peer-reviewed journals, or reports of clinical trial committees and other technology assessment bodies. This includes consideration of whether a drug is included in the American Hospital Formulary Service as appropriate for its proposed use; and
  3. Whether there are consensus opinions of national and local health care providers in the applicable specialty as determined by a sampling of providers, including whether there are protocols used by the treating facility or another facility studying the same drug, device, medical treatment or procedure.

Definitions

Investigational - As determined by HealthPartners, a drug, device or medical treatment or procedure is investigational if reliable evidence does not permit conclusions concerning safety, effectiveness, or effect on health outcomes.

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
  • 05/30/2017 - Effective date
Review date
  • 05/2017

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