01Already effective 10/01/2025 for intraosseous radiofrequency ablation of the basivertebral nerve: Get prior authorization, and document that the member is 18 years of age or older, has had chronic non-radicular low back pain for at least six months, has Type 1 or Type 2 Modic changes shown by MRI in at least one vertebral endplate at one or more levels from L3-S1, has completed at least six months of nonsurgical conservative treatment, and has consulted with a licensed clinical health psychologist with expertise in chronic pain within the last six months.
02The conservative treatment must include avoidance of activities that aggravate pain, pharmacotherapy, and at least 4 physical therapy visits completed within the last six months, with the physical therapist's notes submitted.
03If the member could not complete physical therapy due to progressively worsening pain and disability, the physical therapist's notes must document this, or the clinical documents must include a physician's statement explaining why physical therapy is contraindicated.
04Formulary updates were to be posted by 10/1/25: Descovy no longer requires prior authorization, mirabegron (Myrbetriq) remains on formulary with member costs based on a brand copay, and vibegron (Gemtesa) is added.
05Check current applicability in the formulary at healthpartners.com/formulary.
06Reported as already effective in the historical source, the services Acellular tissue engineered vessel (ATEV, e.g., Symvess) for any indication and implantable ascites pump (e.g., alfapump) are non-covered or investigational.
07Reported as already effective in the historical source, MRgFUS (ExAblate stereotactic ablation lesion, intracranial) for essential tremor is removed from the non-covered policy and prior authorization is not required.
08Effective 10/01/2025, Cohere Health Commercial and Medicaid policies are revised for the listed services, and the posted policies under HealthPartners, Upcoming Policy Changes, should be reviewed.