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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 more…

Medicare plans

For Medicare coverage criteria, click here.

For a list of services requiring Medicare prior authorization, click here.

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

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z All
Viewing 24 of 343 policies
Policy name Policy category Product Prior authorization required
Sacroiliac joint pain treatment procedures Medical Services
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Scar revision/keloids Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Sebelipase Alfa (Kanuma) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Sex therapy, sexual dysfunctions and paraphilic disorders Behavioral Health
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Skilled nursing facility Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Skilled nursing facility - Minnesota Health Care Programs Ancillary Services
MHCP
Yes
Sleep studies Medical Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Sleep studies - Minnesota Health Care Programs Medical Services
MHCP
No
Somatostatin analogues for acromegaly (Sandostatin LAR®, Somatuline Depot®, Signifor LAR®, Somavert®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Speech therapy - habilitative Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Speech therapy - rehabilitative Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Speech therapy - Rehabilitative - Minnesota Health Care Programs Ancillary Services
MHCP
No
Spinal cord and implanted peripheral nerve stimulation Spine
Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Spinal fusion, lumbar Spine
Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Spinal lumbar laminectomy Medical Services
Spine
Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Spinal unloading devices Equipment/Supplies
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Spine surgical practice - low back pain office visits Medical Services
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Statin medications for prevention of cardiovascular disease Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Stereotactic radiosurgery and stereotactic body radiation therapy Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Sublingual immunotherapy (SLIT) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Supprelin LA/Lupron Depot-Peds - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Sympathectomy (thoracic) for the treatment of primary hyperhidrosis Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Synagis (palivizumab) injections for respiratory syncytial virus (RSV) prophylaxis Medical Services
Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Synagis (palivizumab) injections for respiratory syncytial virus (RSV) prophylaxis – Minnesota Health Care Programs Medical Services
Pharmacy
MHCP
Yes
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z All
Viewing 24 of 343 policies