Medical Policy UpdatesHealthPartners 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
| Policy name | Policy category | Product | Prior authorization required |
|---|---|---|---|
| Canakinumab (ILARIS®) |
Pharmacy |
Iowa Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Canakinumab (ILARIS®) – Minnesota Health Care Programs |
Pharmacy |
MHCP |
Yes |
| Caplacizumab-yhdp (Cablivi®) |
Pharmacy |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Capsule endoscopy |
Diagnostic Imaging |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
No |
| Cardiac event monitoring |
Medical Services |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Cardiovascular risk assessments |
Medical Services |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
No |
| Category III CPT codes |
Investigational |
Iowa Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Category III CPT codes – Minnesota Health Care Programs |
Investigational |
MHCP |
No |
| Central precocious puberty drug therapy - Minnesota Health Care Programs |
Pharmacy |
MHCP |
Yes |
| Cerliponase alfa (Brineura®) |
Pharmacy |
Iowa Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Cerliponase alfa (Brineura®) – Minnesota Health Care Programs |
Pharmacy |
MHCP |
Yes |
| Certolizumab (Cimzia®) |
Pharmacy |
Iowa Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Chemical health services |
Behavioral Health |
Iowa Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Chemical health services - Minnesota Health Care Programs |
Behavioral Health |
MHCP |
Yes |
| Chimeric antigen receptor/genetically engineered T-cell receptor (CAR-T) therapy |
Medical Services |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Chiropractic services |
Medical Services |
Iowa Minnesota North Dakota South Dakota Wisconsin |
No |
| Chiropractic services - Minnesota Health Care Programs |
Medical Services |
MHCP |
No |
| Chorionic gonadotropin (Novarel® and Synarel®) – Minnesota Health Care Programs |
Pharmacy |
MHCP |
Yes |
| Chronic pain - multidisciplinary intensive day treatment programs |
Behavioral Health Medical Services |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Circumcision - Minnesota Health Care Programs |
Surgery |
MHCP |
Yes |
| Cleft Lip / Cleft Palate |
Medical Services |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
No |
| Clinical trials: coverage of routine care costs |
Medical Services |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
No |
| Cognitive rehabilitation |
Ancillary Services |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Collagenase (Xiaflex®) |
Pharmacy |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Complementary and alternative medicine |
Administrative |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
No |
| Compounded medications |
Pharmacy |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Compression support garments |
Equipment/Supplies |
Iowa Minnesota North Dakota South Dakota Wisconsin |
No |
| Compression support garments - Minnesota Health Care Programs |
Equipment/Supplies |
MHCP |
No |
| Computed tomography (CT), Magnetic resonance imaging (MRI) and Positron emission tomography (PET) scans |
Diagnostic Imaging |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
No |
| Continuous passive motion (CPM) devices |
Equipment/Supplies |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Cosmetic surgery / treatments |
Surgery |
MHCP Minnesota North Dakota South Dakota Wisconsin |
Yes |
| Cosmetic surgery/treatments - Iowa |
Surgery |
Iowa |
Yes |
| Court-ordered care - mental health |
Behavioral Health |
Iowa MHCP Minnesota North Dakota South Dakota Wisconsin |
No |