ModifiedHealthPartnersPolicy N/A

HealthPartners coverage policy updates (medical, behavioral health, DME & pharmacy)

Summarizes new and revised HealthPartners coverage and prior authorization processes affecting medical, behavioral health, durable medical equipment, and pharmacy (including medical injectables and weight-loss drugs); intended for providers who submit prior authorizations or follow coverage criteria for HealthPartners members.

Policy Summary

PayerHealthPartners

PolicyCoverage - medical, behavioral health, DME & pharmacy updates

Policy CodePolicy N/A

Change TypeCoverage & prior authorization updates (material changes)

Effective DateDec 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests for medical injectables and non-oncology drugs via the HealthPartners Provider Portal online PA form.

SourceLink

POLICY UPDATE CHANGES

PA criteria for weight loss medications (Saxenda, Wegovy & Zepbound) updated to require BMI >=35 kg/m2 for initial approval without risk factors, and BMI >=27 kg/m2 with at least one risk factor; provider attestation of 6 months participation in a weight loss program required.

Cohere Health will manage prior authorization and coverage criteria for a specified list of cardiovascular and musculoskeletal services effective 2/1/2025 for Level Funded Self-Insured Commercial plans.

Prior authorization requests for non-oncology drugs, including medical injectables, will be routed to a new online form via the Provider Portal.

Medicaid policy expanded to include Electrolyte-Containing Fluids (B4102 and B4103) as medically necessary when documented for malabsorption or malnutrition.

Radiofrequency ablative denervation policy revised to remove requirement that the first and second medial branch blocks be performed under fluoroscopic guidance.

2/1/2025Cohere-managed PA effective

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

BMI ≥35 / BMI ≥27Weight-loss BMI thresholds

B4102,B4103Medicaid HCPCS added

ManyService categories moved to Cohere

14 bdAuth contact threshold

Coverage Criteria and Clinical Requirements

inv-01: Initial therapy - Weight-loss medications

Covered when ALL of the following are met:

Initial approval criteria for Saxenda, Wegovy, Zepbound: Member meets BMI threshold: either BMI >=35 kg/m2 for members without specified risk factors OR BMI >=27 kg/m2 with at least one of the following risk factors: hypertension, dyslipidemia, or type II diabetes; provider attests participation in a weight-loss program addressing a reduced calorie diet and exercise for at least 6 months prior to initiation of therapy; drug-specific formulary status may affect coverage (Zepbound added as nonpreferred).BMI criteria

Requires provider attestation of 6 months participation in a weight-loss program

inv-02: PA requirement - Cohere Health services

Covered/provided when prior authorization is obtained through Cohere Health for Level Funded Self-Insured Commercial plans after 2/1/2025:

Cohere-managed services: Prior authorization is required via Cohere Health for the listed cardiovascular and musculoskeletal services (see Cohere guidelines for the full service and code list).effective 2/1/2025

Applies to HealthPartners Level Funded Self-Insured Commercial plans only; other commercial self-insured products continue to be managed by HealthPartners.

inv-03: Medicaid coverage - electrolyte-containing fluids

Covered when ALL of the following are documented:

Electrolyte-containing fluids (B4102/B4103): Ordering physician documents medical necessity related to malabsorption or malnutrition, including applicable diagnoses and estimated length of need; documentation demonstrates the member cannot absorb adequate nutrients or requires fluids; provider documents why other nutritional products do not satisfy the member's needs.medical necessity documentation

Fluids intended solely to provide electrolytes are not covered; provider must discuss benefits and alternatives with the member and document in the medical record.

inv-04: Syphilis screening and treatment criteria

Screening is recommended based on risk factors and specific populations; pregnancy has defined screening intervals.

Risk-based screening: Screen individuals with multiple or new sexual partners; signs or symptoms of syphilis or another STI; those requesting STI screening; sexual partner recently diagnosed with syphilis; men who have sex with men (at least annually; every 3–6 months if increased risk); people living with HIV (at first HIV evaluation and at least annually thereafter); history of incarceration; transgender and gender diverse people (at least annually based on reported behaviors); history of transactional sex; housing instability.

From risk-based screening recommendations.

Pregnancy screening: Screen pregnant people at the first encounter (ideally in the first trimester), early in the third trimester (28–32 weeks' gestation), and at delivery; perform additional screening if there is recent exposure or if testing is requested.minimum 3 screenings during pregnancy

Per MDH and ACOG recommendations.

Presumptive treatment indication:

Per the Medicaid policy update, fluids intended solely to replace electrolytes are not covered. Electrolyte-containing fluids (HCPCS B4102 and B4103) may be medically necessary when the ordering physician documents medical necessity for conditions related to malabsorption or malnutrition, including applicable diagnoses and length of need, and when documentation shows the member cannot absorb adequate nutrients or requires fluids; but fluids provided only for electrolyte replacement are excluded from coverage.

No additional exclusions are explicitly listed in this section beyond the electrolyte-only fluids exclusion described in the Medicaid update.

Language advising providers to "proceed with caution" for certain procedures was removed in Cohere-managed musculoskeletal policy updates; explicit not-medically-necessary determinations are maintained in the posted Cohere coverage policies and should be referenced directly on the HealthPartners/Cohere policy pages.

Within the provided chunks there are no items specifically identified as not medically necessary. The materials focus on expanded screening and treatment recommendations for syphilis and other policy changes rather than listing NMN conditions.

Billing Codes and Thresholds

Medicaid-covered HCPCSHCPCSCovered

B4102	Electrolyte-Containing Fluid (HCPCS) -- as referenced in Medicaid policy
B4103	Electrolyte-Containing Fluid (HCPCS) -- as referenced in Medicaid policy

BMI for weight‑loss medication initial approval

BMI threshold — no risk factors>= 35 kg/m2 for initial approval

BMI threshold — with risk factor(s)>= 27 kg/m2 with at least one of: hypertension, dyslipidemia, or type II diabetes

Provider attestation requirementAttestation of participation in a weight‑loss program (reduced calorie diet and exercise) for at least 6 months prior to initiation

Formulary status noteZepbound added as nonpreferred on the PDL — see HealthPartners formulary for details

BMI criteria for weight‑loss medications

Primary BMI thresholds>= 35 kg/m2 (members without specified risk factors); >= 27 kg/m2 (members with at least one specified risk factor)

What Providers Must Do

Prior Authorization

Cohere Health PA routing (effective 2/1/2025)

For dates of service on or after 2025-02-01, specific cardiovascular and musculoskeletal services for HealthPartners Level Funded Self‑Insured Commercial plans will require prior authorization routing through Cohere Health. Providers should submit PA requests to Cohere for the listed services; Cohere’s coverage criteria and routing will be used (this aligns these level-funded plans with requirements already in place for Fully Insured Commercial, Medicaid, and Medicare Advantage). For dates of service prior to 2025-02-01, continue using HealthPartners’ existing policies and processes.

Effective 2/1/2025: Cohere Health PA routing applies to Level Funded Self‑Insured Commercial plans only
Cohere will not manage PA for other commercial self‑insured products; those remain managed by HealthPartners
Cohere criteria available at Cohere Guidelines (all specialties)

Prior Authorization

Cohere-managed PA list

Services listed for Cohere-managed prior authorization must be submitted through Cohere Health per the routing above. Providers should verify whether a given service for a member’s product is subject to Cohere routing before submitting to HealthPartners.

Initial Therapy Requirements

inv-25: Initial therapy - weight-loss drugs

Initial approval requirements for specified GLP‑1 weight-loss agents:

Initial approval: Member meets BMI thresholds as specified (BMI >=35 kg/m2 without risk factors, or BMI >=27 kg/m2 with at least one of: hypertension, dyslipidemia, or type II diabetes); provider documents and attests to participation in a weight-loss program addressing reduced calorie diet and exercise for at least 6 months prior to initiation; note formulary status may change coverage and Zepbound is listed as nonpreferred on the formulary.BMI and program attestation

Provider attestation of 6 months documented program is required prior to approval.

inv-26: Presumptive syphilis treatment

Presumptive treatment is indicated when any of the following are present:

Presumptive treatment indications: Treat individuals who have signs of primary or secondary syphilis; who report sexual contact with someone diagnosed with syphilis; or who have an initial reactive rapid syphilis test and follow-up for treatment is uncertain.

Step Therapy and Program Attestation

Step	Requirement	Duration / Notes
1
Provider attestation of participation in a weight loss program addressing a reduced calorie diet and exercise
At least 6 months prior to initiation of therapy; required for prior authorization for weight-loss medications (Saxenda, Wegovy, Zepbound).

Site of Care and Screening Settings

Billing Rule

Use online Provider Portal form for injectable PA requests

Prior authorization requests for medical injectables must be submitted via the online Provider Portal form; there is no site‑specific administration restriction noted in this policy update.

Note

Screen for syphilis in all relevant care settings

Providers should screen for syphilis in any health care setting, including primary care, correctional facilities, substance use treatment facilities, emergency departments, urgent care, and other settings serving high‑risk populations.

Background and Scope

This bulletin summarizes administrative and clinical coverage updates across HealthPartners lines of business, including transitions of prior-authorization management for specified cardiovascular and musculoskeletal services to Cohere Health for Level Funded Self‑Insured Commercial plans, updates to pharmacy prior authorization workflows (including medical injectables), and clinical-threshold changes for weight‑loss medications and select Medicaid coverage expansions.

Policy Summary

PayerHealthPartners

PolicyCoverage - medical, behavioral health, DME & pharmacy updates

Policy CodePolicy N/A

Change TypeCoverage & prior authorization updates (material changes)

Effective DateDec 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests for medical injectables and non-oncology drugs via the HealthPartners Provider Portal online PA form.

SourceLink

On This Page

Provide presumptive syphilis treatment for persons with signs of primary or secondary syphilis, those reporting sexual contact with someone with syphilis, or individuals with an initial reactive rapid syphilis test when follow-up for treatment is uncertain.

From treatment considerations; refer to MDH guidance for further management.

Specified risk factorsHypertension, dyslipidemia, or type II diabetes

Program attestationProvider must attest to 6 months participation in a weight‑loss program addressing reduced calorie diet and exercise prior to initiation

Reverse algorithm for syphilis screening

Preferred screening algorithmThe reverse algorithm is generally preferred for syphilis screening to detect early infection and late, untreated infection

AcceptabilityEither reverse or traditional algorithm is acceptable; local factors should guide laboratory approach

Clinical resourcesSee regional clinical guidance (e.g., California Prevention Treatment Center) for algorithm interpretation

Cohere-managed PA list includes: cardiac ablation; cardiac implantable devices; carotid artery stenting and TCAR; carotid endarterectomy; catheter-based lower extremity angiogram; coronary artery atherectomy; descending thoracic and abdominal aortic repair; electrophysiology study; mobile cardiac telemetry and external wearable devices; internal loop recorders; leadless pacemakers; left and right heart catheterization and coronary angiography; left atrial appendage implants; lower extremity arterial revascularization (and more as listed in Cohere guidance)
A consolidated list of specific codes requiring PA is available via the link in provider communications

Note

Prior authorization notice

Prior authorization processes and availability notices: Prior authorization for some services is changing (see Cohere routing above). Additionally, prior authorization for Medicare urine drug testing is delayed until further notice. For specific patient inquiries about delayed authorizations, contact Medical Policy Intake.

Medicare urine drug testing PA is delayed until further notice — contact Medical Policy Intake at 952-883-5724 for case-specific questions
For questions about Cohere routing or whether a service requires PA, check the Cohere Guidelines or contact HealthPartners Provider Services

Documentation Required

Electrolyte-containing fluids documentation

For electrolyte-containing fluids (HCPCS B4102 and B4103), the ordering physician must document medical necessity in the chart, including applicable diagnoses and expected length of need. Documentation must show the member cannot absorb adequate nutrients or requires fluids; fluids prescribed solely to supply electrolytes are not covered. Providers must discuss benefits vs alternatives with the member and document why other nutritional products do not meet the member’s needs.

Affected HCPCS: B4102, B4103
Documentation must include: applicable diagnosis, length of need, rationale that other nutritional products are inadequate, and discussion with the member

Note

Authorization follow-up

If authorizations or care coordination requests have been delayed beyond expected timeframes (for example, more than 14 business days during recent system transitions), contact the assigned Care Coordinator. For MSHO/MSC+ questions or to escalate delays, call MSHO/MSC+ Service Coordinators.

If waiting more than 14 business days for an authorization, contact the assigned Care Coordinator
MSHO/MSC+ Service Coordinators: 952-883-7775

Prior Authorization

Weight‑loss medication conservative management

Weight‑loss medication prior authorization criteria were updated. Prior to initiating pharmacotherapy, providers must document conservative management: participation in a structured weight‑loss program (reduced‑calorie diet and exercise) for at least 6 months, with provider attestation. BMI and risk‑factor thresholds apply for initial approval.

Required conservative management: provider attestation of participation in a weight‑loss program (reduced calorie diet + exercise) for ≥ 6 months prior to medication start
BMI thresholds for initial approval: ≥35 kg/m2 without risk factors; ≥27 kg/m2 with at least one risk factor (hypertension, dyslipidemia, type II diabetes)
Zepbound added as nonpreferred on the PDL—see formulary at healthpartners.com/formularies for details

See MDH Syphilis Information for Health Professionals for further guidance.