Find a Doctor Contact Us SIGN IN OR REGISTER HOME PLANS GETTING CARE COVERAGE & BENEFITS HEALTH & WELLNESS Medical Policy | Pre-certification | Prior Authorization Medical Policy Terms of Use: PreferredOne: Clinical Policies Agreement Please read the following terms and conditions. If you agree to them, click on 'Accept Terms' below. If you do not agree to these terms, click on 'Decline' and you will be returned to the PreferredOne home page. Clinical policies accessible through this site serve as a guide for use in making benefit coverage recommendations or determinations or in evaluating the medical necessity of services for enrollees of: PreferredOne Community Health Plan (PCHP), a health maintenance organization; and PreferredOne Insurance Company (PIC); and Certain self-funded plans administered by PreferredOne Administrative Services, Inc. (PAS), a third-party administrator; and Benefit plans receiving certain services from PreferredOne, a preferred provider organization. Enrollees of PreferredOne Community Health Plan (PCHP), PreferredOne Insurance Company (PIC), and some non-ERISA group health plans that PreferredOne Administrative Services, Inc. (PAS) administers are eligible to receive all benefits mandated by the state of Minnesota. These clinical policies do not constitute or serve as a substitute for medical treatment or advice, nor do they constitute or serve as a substitute for the exercise of independent medical judgment in enrollee specific matters. They are intended to promote objectivity and consistency in the health care coverage decision-making process and are necessarily general in approach. Therefore, medical discretion must be exercised in their application. Additional information may be required and requested by PCHP, PIC, or PAS, or its designee , before coverage determinations or recommendations can be made. Benefits are available to enrollees only for covered services specified in the enrollee's benefit plan document. Benefits are not available if a service is excluded by a health plan from coverage. Exclusions from coverage typically include, but are not limited to, health care services that are not medically necessary as determined by PCHP, PIC, or PAS, or its designee. Final coverage determinations are based on the applicable plan language. To the extent there is any inconsistency between a clinical policy set forth on this site and the terms of an enrollee's benefit plan, the terms of the enrollee's benefit plan will always control. Please call the Customer Service telephone number listed on the back of the enrollee's identification card for applicable pre-certification/notification requirements and/or to obtain paper copies of policies included in this web site. ACCEPT TERMS DECLINE ABCDEFGHILMNOPRSTV A Ambulance Services MP/A006 Anesthesia Services for Routine Screening and Diagnostic Gastrointestinal Endoscopic Procedures MC/G013 B Bariatric Surgery for Obesity MC/H003 Behavioral Health, Autism Spectrum Disorders in Children: Assessment, Evaluation and Treatment MC/M026 Behavioral Health, Court Ordered Mental Health Services MP/C001 Behavioral Health, Court-Ordered Substance Use Related Disorder Services MP/C011 Behavioral Health, Eating Disorders: Level of Care Criteria MC/M005 Behavioral Health, Mental Health and Substance Related Disorders: Residential Treatment MC/M007 Behavioral Health, Mental Health Disorders: Inpatient Treatment MC/M001 (Revised) Behavioral Health, Mental Health Disorders: Intensive Residential Treatment Services (IRTS) MC/M023 (Revised) Behavioral Health, Mental Health Disorders: Residential Crisis Stabilization Services (CSS) MC/M022 (Revised) Behavioral Health, Substance Related Disorders Detoxification and Addiction Stabilization: Inpatient Treatment MC/M014 Behavioral Health, Substance Related Disorders: Inpatient Primary Treatment MC/M010 Bone Growth Stimulators (Osteogenic): Electrical and Ultrasonic MC/F021 Breast Reconstruction MC/G004 Breast Reduction and Gynecomastia Surgery MC/G002 (Revised) C Cardiac Devices and Procedures for Occlusion of Left Atrial Appendage MC/A008 Chest Wall Deformities (Pectus Excavatum and Poland Syndrome), Surgical Reconstruction MC/A009 (New) Chiropractic Services MC/N009 (New) Clinical Policy Application, Development, Oversight, and Distribution MP/C014 (Revised) Clinical Trials MP/C008 Cosmetic Procedures/Treatments MP/C002 (Revised) Coverage Determination Guidelines MP/C009 (Revised) Cryoablation/Cryosurgery for Oncology Indications MC/I007 D Dental Services, Hospitalization, and Anesthesia for Dental Services Coverage Under Medical Benefit MC/B004 Dental Services, Pediatric Orthodontic Coverage Under Medical Benefit MC/B003 DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies) MP/D004 (Revised) DMEPOS, Continuous Glucose Monitoring Systems for Long-term Use MC/L008 DMEPOS, Dressing Supplies MP/D008 (Revised) DMEPOS, Insulin Infusion Pump MC/L011 DMEPOS, Lower Limb Prostheses MC/D005 DMEPOS, Pneumatic Compression Devices and Heat/Cold Therapy Units MC/D006 DMEPOS, Standing Systems and Gait Trainers MC/D007 DMEPOS, Upper Limb Prostheses MC/D004 DMEPOS, Wheelchairs and Mobility Assistive Equipment MC/D003 Drug Testing in Substance Abuse Treatment and Chronic Pain Management Settings MC/L022 (Revised) E Eyelid and Brow Surgery MC/G001 F FDA-Approved Humanitarian Use Devices (HUD) MP/H008 Fetal Procedures In Utero MC/G017 Free-Standing Birth Centers and Associated Covered Services MP/F007 G Gender Reassignment MC/G014 Genetic Testing, Comparative Genomic Hybridization (CGH, aCGH) MC/L015 Genetic Testing, Hereditary and Somatic Conditions MP/G001 (Revised) Genetic Testing, Hereditary Cancer Syndromes MC/L010 (Revised) Genetic Testing, Preimplantation Genetic Diagnosis MC/L026 (New) Genetic Testing, Reproductive Carrier Screening MC/L017 Genetic Testing, Whole Exome Sequencing MC/L021 H Hearing Devices MP/H006 Home Health Services, Intermittent MC/N007 Home Health Services, Private Duty/Extended Hours MC/N008 Hospice Services MP/H007 Hyperbaric Oxygen Therapy MC/G011 Hyperhidrosis Surgery MC/G008 I Infertility Services MP/I002 Intervertebral Disc Prosthesis, Cervical and Lumbar MC/F022 (Revised) Investigative Services MP/I001 L Laboratory Testing for Detection of Heart Transplant Rejection MC/L014 Laboratory Tests MP/L001 Levels of Evidence and the Evaluation of Health Care Services MP/L004 (Revised) Lipoma Removal MC/G015 M Molecular Testing, Tumor/Neoplasm Biomarkers MP/M001 Molecular Testing, Gene Expression MC/L012 (Revised) N Neuromodulation, Transcranial Magnetic Stimulation (TMS) MC/M025 (Revised) Neurostimulation, Deep Brain and Cortical Brain (Responsive Cortical) MC/I009 (Revised) Neurostimulation, Hypoglossal Nerve MC/I012 (Revised) Neurostimulation, Sacral Nerve MC/I008 (Revised) Neurostimulation, Spinal Cord/Dorsal Column and Dorsal Root Ganglion MC/I010 (Revised) Nuclear Medicine, Cardiac Positron Emission Tomography (PET)/CT MC/L023 Nutritional Counseling MP/N002 (Revised) O Obstructive Sleep Apnea, Non-Surgical Treatment MC/C011 (Revised) Obstructive Sleep Apnea, Surgical Treatment in Adults MC/C007 Occupational and Physical Therapy MC/N003 Orthognathic Surgery MC/B002 P Panniculectomy, Excision/Removal Redundant Skin/Tissue MC/G003 Pharmacogenetic/Pharmacogenomic Testing and Serological Testing for Inflammatory Conditions MP/P013 (Revised) Physician Directed/Medically Supervised Weight Loss Programs MP/W001 Preventive Coverage for Breast Cancer Screening MP/P019 Preventive Coverage for Cervical Cancer Screening MP/P018 Preventive Coverage for Colorectal Cancer Screening MP/P014 (Revised) Preventive Coverage for Lung Cancer Screening MP/P017 (Revised) Preventive Coverage for Osteoporosis Screening MP/P016 Preventive Coverage for Prenatal Services MP/P015 (Revised) Preventive Coverage for Routine Immunizations MP/P020 Preventive Coverage of Health Care Services MP/P012 (New) R Radiation Therapy, Intensity Modulated (IMRT) MC/L009 Radiation Therapy, Neutron Beam MC/L024 Radiation Therapy, Proton Beam MC/L020 Radiation Therapy, Selective Internal Microspheres (SIRT) MC/L025 Radiation Therapy, Stereotactic Body Radiation Therapy or Stereotactic Radiosurgery MC/L013 Radiofrequency Ablation (Neurotomy, Denervation, Rhizotomy) Cervical, Thoracic, Lumbosacral, Sacroiliac or Knee Pain MC/F024 Reconstructive Surgery MP/R002 (Revised) Rhinoplasty and Excision of Nasal Dermoid Cyst MC/C001 Risk Reducing Mastectomy or Salpingo-Oophorectomy MC/G007 (New) S Scar Revision MC/G016 Skilled Nursing Facility Services MC/N002 (Revised) Special Coverage for the COVID-19 Pandemic MP/C015 (Revised) Speech Therapy: Outpatient Setting MC/N004 (Revised) T Therapeutic Pass MP/T004 (Revised) Total Joint Arthroplasty of Knee or Hip, Elective MC/F025 (Revised) Transplantation, Bone Marrow MC/T001 (Revised) Transplantation, Designated Transplant Network Provider MP/T006 Transplantation, Solid Organ MC/T008 (Revised) V Varicose Vein Treatments MC/J001 (Revised) Ventricular Assist Devices (VAD) and Total Artificial Heart (TAH) MC/A006 Search DMEPOS List Investigative Services Milliman Care Guidelines NCCN Guidelines Pharmacy Policy Prior Authorization Forms Prior Authorization List United Healthcare Coverage Guidelines UPDATES & NEWS Medical Policy and Pharmacy Policy Future Updates Provider Newsletters CONTACT US Phone: 763-847-4477 Toll Free: 1-800-997-1750 TTY: 763-847-4013 PreferredOne Corporate Office 6105 Golden Hills Drive Golden Valley MN 55416-1023 COMPANY About PreferredOne Careers Community News & Stories Board Elections RESOURCES For Members For Employers For Brokers For Providers For Payors Data Practices Privacy Practices 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