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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 27 of 325 policies
Policy name Policy category Product Prior authorization required
Panniculectomy Surgery
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Panniculectomy – Minnesota Health Care Programs Surgery
MHCP
Yes
Pectus excavatum & pectus carinatum Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Pegloticase (Krystexxa®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Pegloticase (Krystexxa®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Percutaneous tibial nerve stimulation (PTNS) for overactive bladder Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Peripheral nerve block injections - diabetic peripheral neuropathy (chronic pain) Investigational
Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Personal care assistant (PCA) - Minnesota Health Care Programs Ancillary Services
MHCP
Yes
Physical & occupational therapy - rehabilitative-Minnesota Health Care Programs Ancillary Services
MHCP
No
Physical and occupational therapy - habilitative Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Physical and occupational therapy - rehabilitative Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Plerixafor (Mozobil®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Pneumatic compression devices Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Pneumatic compression devices and cold/heat therapy units – Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Pompe disease enzyme replacement therapy - alglucosidase alfa (Myozyme® and Lumizyme®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Pompe disease enzyme replacement therapy – alglucosidase alfa (Myozyme® and Lumizyme®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Port-wine stain treatment Medical Services
MHCP
Minnesota
Wisconsin
No
Port-wine stain treatment – Iowa - North Dakota - South Dakota Medical Services
Iowa
North Dakota
South Dakota
No
Pressure reducing support surfaces Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Preventive services Medical Services
Preventive
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Private duty aide in hospital or skilled nursing facility Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Prophylactic mastectomy Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Prosthesis - lower limb Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Prosthesis - upper limb Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Protective helmets Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Protective helmets – Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Proton beam radiation therapy Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
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 27 of 325 policies