Medical Policy UpdatesCoOportunity Health has Medical Policies that contain coverage criteria and guidelines that describe how we make coverage decisions for certain health care services and items. Please call our Member Services Department at 1.888.324.2064 if you have any questions.
The information presented regarding coverage criteria and guidelines is regularly updated and is subject to change without notice. Read more…
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 |
|---|---|---|---|
| Abatacept (Orencia) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Abdominoplasty/panniculectomy | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Access to outpatient behavioral health services | Behavioral Health | CoOportunity Health Iowa Nebraska | Yes |
| Actigraphy | Medical Services Investigational | CoOportunity Health Iowa Nebraska | No |
| Actinic keratoses treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Acupuncture | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Ado-trastuzumab (Kadcyla®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Adoption | Other | CoOportunity Health Iowa Nebraska | No |
| Advanced drug therapy for pulmonary hypertension: epoprostenol (generic, Flolan® and Veletri®), treprostinil (Remodulin® null), iloprost (Ventavis®) and sildenafil injection (Revatio®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Air compressor | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Air-fluidized specialty bed (group III) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Airway clearance system/chest compression generator system | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Alemtuzumab (Lemtrada™) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Allergy testing immunotherapy | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Allograft transplant for orthopedic procedures of the knee (e.g., DeNovo®NT) | Investigational Medical Services Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Alopecia areata treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: Alpha-1 Proteinase Inhibitor (Aralast NP®, Glassia®, Prolastin®-C and Zemaira®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Ambu bag | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Ambulance & medical transportation | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Ankle replacement surgery | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Anti-nausea wristband | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Apheresis | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Apnea monitor | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Aqua K pad and pump | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Artificial insemination (AI) or intra-uterine insemination (IUI) | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Artificial intervertebral disc replacement - cervical | Surgery Spine Medical Services | CoOportunity Health Iowa Nebraska | Yes |
| Artificial intervertebral disc replacement - lumbar | Investigational Spine | CoOportunity Health Iowa Nebraska | No |
| Asparaginase Erwinia chrysanthemi (Erwinaze®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Augmentative communication device | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Autism services - Nebraska | Behavioral Health | CoOportunity Health Nebraska | Yes |
| Autologous bone marrow grafting (ABMG) for osteonecrosis | Surgery | CoOportunity Health Iowa Nebraska | No |
| Autologous chondrocyte implantation (ACI) | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Autologus platelet rich plasma (PRP) injections | Medical Services Investigational | CoOportunity Health Iowa Nebraska | No |
| Autopsy | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Bath bench/chair (non-Hospice) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Batteries | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Bed pan | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Bedwetting/enuresis alarms | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Belimumab (Benlysta®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Belinostat (Beleodaq®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Bevacizimab (Avastin®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Bilirubin lights | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Bio-identical hormone replacement and saliva hormone testing for treatment of menopause | Medical Services Investigational | CoOportunity Health Iowa Nebraska | No |
| Biofeedback for behavioral health applications | Equipment/Supplies Behavioral Health | CoOportunity Health Iowa Nebraska | No |
| Biofeedback medical applications - Iowa | Ancillary Services | CoOportunity Health Iowa | No |
| Biofeedback – medical applications - Nebraska | Equipment/Supplies | Nebraska | No |
| Birth centers | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Blepharoplasty/ptosis repair, brow lift | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Blinatumomab (Blincyto™) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Blood factor products | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Blood pressure monitors/units | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Bone mineral densitometry | Diagnostic Imaging | CoOportunity Health Iowa Nebraska | No |
| Bone stimulators, electronic and ultrasonic | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Botulinum toxins: abobotulinumtoxinA (Dysport®), incobotulinumtoxinA (Xeomin®), onabotulinumtoxinA (Botox®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Brachytherapy for prostate cancer | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Breast prosthesis | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Breast pumps | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Breast specific gamma imaging (BSGI) | Diagnostic Imaging | CoOportunity Health Iowa Nebraska | Yes |
| Breast surgery | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Brentuximab vedotin (Adcetris®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Bronchial drainage (BD) board | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Bronchial drainage (BD) table | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Bronchial thermoplasty | Medical Services | CoOportunity Health Iowa Nebraska | Yes |
| Bronchial valve placement in emphysema | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Cabazitaxel (Jevtana®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Cane or Crutches | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Capsule endoscopy – wireless | Diagnostic Imaging | CoOportunity Health Iowa Nebraska | No |
| Cardiac event monitoring | Medical Services | CoOportunity Health Iowa Nebraska | Yes |
| Cardiac rehabilitation | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Cardiac resynchronization therapy (CRT) | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Cardiovascular risk assessments | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Cardioverter-defibrillator, implantable | Surgery | CoOportunity Health Iowa Nebraska | No |
| Carfilzomib (Kyprolis®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Certolizumab (Cimzia®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Cetuximab (Erbitux®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Chelation therapy | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Chemical health residential services | Behavioral Health | CoOportunity Health Iowa Nebraska | Yes |
| Cleft lip/cleft palate | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Clinical trials – coverage of routine care costs | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Cochlear implants & auditory brainstem implants | Surgery | CoOportunity Health Iowa Nebraska | No |
| Cognitive rehabilitation | Ancillary Services | CoOportunity Health Iowa Nebraska | Yes |
| Cold compression therapy | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Collagenase (Xiaflex®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Colorectal cancer (CRC) screening with stool based DNA testing (Cologuard®) | Investigational Laboratory | CoOportunity Health Iowa Nebraska | Yes |
| Commode | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Compounded medications | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Compression support garments | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Computed tomography (CT), Magnetic resonance imaging (MRI), and Positron emission tomography (PET) scans | Diagnostic Imaging | CoOportunity Health Iowa Nebraska | No |
| Computerized dynamic posturography | Investigational | CoOportunity Health Iowa Nebraska | No |
| Cone Beam CT Scan for Medically-related Dental Services | Diagnostic Imaging | CoOportunity Health Iowa Nebraska | Yes |
| Continuous glucose monitoring systems (CGMS) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Continuous passive motion (CPM) devices | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Continuous positive airway pressure (CPAP) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Cosmetic surgery/treatments | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Cranial electrotherapy stimulation | Behavioral Health | CoOportunity Health Iowa Nebraska | No |
| Cranial reshaping helmet/band | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Cryoablation treatment of benign breast fibroadenomas | Investigational | CoOportunity Health Iowa Nebraska | No |
| Cryopyrin-associated periodic syndromes (CAPS) drug therapy | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Cryosurgical ablation for prostate cancer | Surgery | CoOportunity Health Iowa Nebraska | No |
| Cryosurgical/radiofrequency ablation of hepatic tumors | Surgery | CoOportunity Health Iowa Nebraska | No |
| Cushions | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Danny sling | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Decompression therapy for chronic low back pain | Investigational Spine | CoOportunity Health Iowa Nebraska | No |
| Deep brain stimulation for neurological movement disorders | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Denosumab (Prolia® and Xgeva®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Dental services – accidental dental | Medical Dental | CoOportunity Health Iowa Nebraska | Yes |
| Dental services – ambulatory hospitalization and anesthesia for dental care | Medical Dental | CoOportunity Health Iowa Nebraska | Yes |
| Dental services – medically necessary outpatient | Medical Dental | CoOportunity Health Iowa Nebraska | Yes |
| Dental services – oral surgery | Medical Dental | CoOportunity Health Iowa Nebraska | No |
| Diabetes education | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Diabetic monitors/meters | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Diabetic supplies | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Dietitian consultation | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Direct-to-consumer (DTC) laboratory testing | Laboratory | CoOportunity Health Iowa Nebraska | No |
| Discography/intradiscal steroid injections | Medical Services Spine | CoOportunity Health Iowa Nebraska | Yes |
| Disposable supplies | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Donor lymphocyte infusion (DLI) | Medical Services Transplants | CoOportunity Health Iowa Nebraska | No |
| Dorsal rhizotomy for spasticity | Surgery | CoOportunity Health Iowa Nebraska | No |
| DOSER™ for inhaled medications | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Dressing supplies | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Dry needling | Investigational Medical Services | CoOportunity Health Iowa Nebraska | No |
| Durable Medical Equipment (DME) and prosthetics | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Ear lobe repair | Surgery | CoOportunity Health Iowa Nebraska | No |
| Eculizumab (Soliris®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Educational materials | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Electric Tumor Treatment Fields (ETTF) to treat glioblastoma, i.e. NovoTTF-100A | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Electrodes | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Endoscopic gastroplasty/gastroplication for GERD | Surgery | CoOportunity Health Iowa Nebraska | No |
| Enema | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Enhanced external counterpulsation (EECP) | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Enteral formula and nutritional supplements | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Epidural steroid injections (ESI) for low back pain - Effective 7/1/2015 | Medical Services Spine | CoOportunity Health Iowa Nebraska | No |
| Epidural steroid injections (ESI) for low back pain - Retire 7/1/2015 | Medical Services Spine | CoOportunity Health Iowa Nebraska | Yes |
| Equipment in skilled nursing facility/long term care facility | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Eribulin (Halaven®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Erythropoiesis stimulating agents (ESA) – (e.g., Procrit®, Epogen® and Aranesp®) | Pharmacy | CoOportunity Health Iowa Nebraska | No |
| Esophageal pH monitoring | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Esteem® totally implantable hearing system | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Extracorporeal shock wave treatment (ESWT) for musculoskeletal conditions | Investigational Medical Services | CoOportunity Health Iowa Nebraska | No |
| Eye surgery – refractive | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Eyewear | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Eyewear for children | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Fecal microbiota transplant | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Feeding/oral function therapy, pediatric | Medical Services | CoOportunity Health Iowa Nebraska | Yes |
| Flutter device | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Foot care | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Formula – amino acid based elemental | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Functional capacity evaluations (FCE/FCA) | Other | CoOportunity Health Iowa Nebraska | No |
| Functional electrical stimulation (FES) in the home | Equipment/Supplies Investigational | CoOportunity Health Iowa Nebraska | No |
| Gender reassignment surgery | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Genetic counseling | Ancillary Services Genetics | CoOportunity Health Iowa Nebraska | No |
| Genetic testing for breast/ovarian cancer predispostion (BRCA genetic testing) | Laboratory | CoOportunity Health Iowa Nebraska | Yes |
| Genetic testing for hereditary cardiac and cardiovascular disease | Laboratory | CoOportunity Health Iowa Nebraska | Yes |
| Genetic testing for hereditary colorectal cancer susceptibility | Laboratory Genetics | CoOportunity Health Iowa Nebraska | Yes |
| Genetic testing for idiopathic scoliosis – ScoliScore™ | Laboratory Genetics | CoOportunity Health Iowa Nebraska | No |
| Genetic testing for reproductive planning and prenatal diagnosis | Laboratory Genetics | CoOportunity Health Iowa Nebraska | No |
| Glaucoma treatment: minimally invasive glaucoma surgery devices | Investigational Medical Services Surgery | CoOportunity Health Iowa Nebraska | No |
| Golimumab (Simponi ARIA®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| GraftJacket® regenerative tissue matrix | Investigational | CoOportunity Health Iowa Nebraska | No |
| Growth deficiency therapy | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Guest houses | Other | CoOportunity Health Iowa Nebraska | No |
| Gynecomastia surgery for males | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Haberman Feeder and nipples | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Health club/fitness center | Other | CoOportunity Health Iowa Nebraska | No |
| Health education | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Hearing aids | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Hearing services | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Heart volume reduction | Surgery | CoOportunity Health Iowa Nebraska | No |
| Helmets | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Hemangioma treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Hereditary angioedema (HAE) drug therapy | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Holistic medicine | Other | CoOportunity Health Iowa Nebraska | No |
| Home health service | Ancillary Services | CoOportunity Health Iowa Nebraska | Yes |
| Home phototherapy | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Home spirometry program | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Hospice services | Ancillary Services | CoOportunity Health Iowa Nebraska | Yes |
| Hospital bed | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Humidifier | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Hyperbaric oxygen therapy | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Hyperhidrosis (primary) treatments | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Hyperthermia – oncology applications | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Immune globulin therapy | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Immunizations | Pharmacy Preventive | CoOportunity Health Iowa Nebraska | No |
| Implantable vagus nerve stimulation (VNS) | Surgery Behavioral Health | CoOportunity Health Iowa Nebraska | Yes |
| In vitro fertilization (IVF) and other advanced assisted reproductive technology (ART) | Medical Services | CoOportunity Health Iowa Nebraska | No |
| In-exsufflation devices | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| In-home mental health psychotherapy services | Behavioral Health | CoOportunity Health Iowa Nebraska | Yes |
| Infertility diagnosis – female | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Infertility diagnosis – male | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Infertility treatment – female | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Infertility treatment – male | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Infliximab (Remicade®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Insulin pumps | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Intensive dietary counseling for obesity for adults | Ancillary Services Medical Services | CoOportunity Health Iowa Nebraska | No |
| Intensive early intervention behavioral therapy (IEIBT) | Behavioral Health | CoOportunity Health Iowa | No |
| Interferential current stimulation (IFC) | Equipment/Supplies Investigational | CoOportunity Health Iowa Nebraska | No |
| Intermittent positive pressure breathing (IPPB) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Interspinous process decompression to treat spinal stenosis (X–STOP®) | Surgery | CoOportunity Health Iowa Nebraska | No |
| Intra-articular Hyaluronan (Viscosupplementation) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Intraocular lens (IOL) implant after cataract surgery | Surgery | CoOportunity Health Iowa Nebraska | No |
| Intraoperative monitoring (IOM) of electromyographic (EMG) responses during spinal surgery | Surgery | CoOportunity Health Iowa Nebraska | No |
| Intrathecal baclofen | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Intravenous (IV) therapy and pump supplies | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Investigational services | Investigational Behavioral Health | CoOportunity Health Iowa Nebraska | Yes |
| Investigational services - list of non-covered services | Investigational Behavioral Health Spine | CoOportunity Health Iowa Nebraska | No |
| Investigational services – category III codes | Investigational | CoOportunity Health Iowa Nebraska | Yes |
| Iontophoresis | Medical Services Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Ipilimumab (Yervoy™) | Pharmacy | CoOportunity Health Iowa Nebraska | No |
| Juvenile court ordered examination | Behavioral Health Medical Services | CoOportunity Health Iowa Nebraska | No |
| K-Y jelly | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Knee arthroscopy: lavage and debridement for osteoarthritis | Surgery | CoOportunity Health Iowa Nebraska | No |
| Knee sleeve | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Labor charges, repairs and parts for Durable Medical Equipment (DME) – prosthetics and orthotics | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Laser treatment for skin conditions | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Laser-assisted uvulopalatoplasty (LAUP) | Surgery | CoOportunity Health Iowa Nebraska | No |
| Lift chair mechanism | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Light therapy unit for seasonal affective disorder | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Lipid apheresis | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Low level laser therapy (cold laser) and high power laser therapy | Investigational | CoOportunity Health Iowa Nebraska | No |
| Low-dose computed tomography (CT) for screening for lung cancer | Diagnostic Imaging Medical Services Preventive | CoOportunity Health Iowa Nebraska | No |
| Lyme disease – antibiotic treatment | Pharmacy | CoOportunity Health Iowa Nebraska | No |
| Magnetic resonance imaging (MRI) focused ultrasound ablation for uterine fibroids | Surgery | CoOportunity Health Iowa Nebraska | No |
| Maintenance care | Other | CoOportunity Health Iowa Nebraska | No |
| Massage therapy | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Mechanical stretch devices | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Medic alert bracelet | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Medically necessary/medical necessity | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Medication therapy disease management program | Pharmacy | CoOportunity Health Iowa Nebraska | No |
| Medications for risk reduction of primary breast cancer in women | Pharmacy Preventive | CoOportunity Health Iowa Nebraska | Yes |
| Meniere's disease treatment – Meniett device | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Mesenchymal stem cell therapy for orthopedic indications | Investigational Surgery | CoOportunity Health Iowa Nebraska | No |
| Microprocessor knee prosthetic | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Minimally invasive & laser spine procedures | Spine Investigational Surgery | CoOportunity Health Iowa Nebraska | Yes |
| MiniMaze™ procedure | Surgery | CoOportunity Health Iowa Nebraska | No |
| Minimum/maximum drug dosage | Pharmacy | CoOportunity Health Iowa Nebraska | No |
| Mole, nevus, lipoma or skin lesion removal | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Mozobil (Plerixafor®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Mucopolysaccharidoses (MPS) drug therapy | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Musculoskeletal treatment (chiropractic) services | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Naltrexone for extended-release (Vivitrol®) | Pharmacy | CoOportunity Health Iowa Nebraska | No |
| Natalizumab (Tysabri®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Nebulizer | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Needles/syringes | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Negative Pressure Wound Therapy (NPWT) / Vacuum-Assisted Wound Closure Therapy (V.A.C.) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Nerve conduction studies (using automated devices) | Investigational | CoOportunity Health Iowa Nebraska | No |
| Neuromuscular electrical stimulator (NMES) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Neuropsychological testing | Behavioral Health Medical Services | CoOportunity Health Iowa Nebraska | No |
| Nivolumab (Opdivo®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Obinutuzumab (Gazyva®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Occipital Nerve Injections or Radiofrequency Ablation (RFA) to treat Cervicogenic Headache and Occipital Neuralgia | Medical Services Investigational | CoOportunity Health Iowa Nebraska | Yes |
| Ofatumumab (Arzerra®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Omacetaxine mepesuccinate (Synribo®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Omalizumab (Xolair®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Oncotype DX™ assay for breast cancer recurrence | Laboratory Genetics | CoOportunity Health Iowa Nebraska | No |
| Oral appliances for sleep disorders | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Orthognathic surgery | Medical Dental | CoOportunity Health Iowa Nebraska | No |
| Orthotics/braces | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Ostomy supplies | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Otoplasty | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Outdoor behavioral health programs | Behavioral Health | CoOportunity Health Iowa Nebraska | Yes |
| Ovarian cancer screening | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Oximeter | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Oxygen | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Palatal implants for obstructive sleep apnea | Surgery | CoOportunity Health Iowa Nebraska | No |
| Pancreas transplantation | Transplants | CoOportunity Health Iowa Nebraska | Yes |
| Panitumumab (Vectibix®) | Pharmacy | CoOportunity Health Iowa Nebraska | No |
| Paraffin bath/portable | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Parenteral therapy | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Patient lifts (Hoyer™, etc) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Peak flow meter | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Pectus carinatum and pectus excavatum | Surgery | CoOportunity Health Iowa Nebraska | No |
| Pegloticase (Krystexxa®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Pelvic floor electrical stimulator for urinary incontinence | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Pembrolizumab (Keytruda®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Penile implants (penile prosthesis) | Surgery | CoOportunity Health Iowa Nebraska | No |
| Percussor | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Percutaneous tibial nerve stimulation (PTNS) for overactive bladder | Medical Services | CoOportunity Health Iowa Nebraska | Yes |
| Percutaneous vertebroplasty and kyphoplasty | Surgery | CoOportunity Health Iowa Nebraska | No |
| Peripheral nerve block injections - diabetic peripheral neuropathy (chronic pain) | Investigational Medical Services | CoOportunity Health Iowa Nebraska | No |
| Pertuzumab (Perjeta®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Pharmacogenetic testing | Laboratory Behavioral Health Genetics | CoOportunity Health Iowa Nebraska | Yes |
| Phenylketonuria (PKU) food products | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Photodynamic therapy (PDT) for age-related macular degeneration | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Photodynamic therapy (PDT) for head and neck tracheobronchial and esophageal cancer | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Physical and occupational therapy - outpatient habilitative | Ancillary Services | CoOportunity Health Iowa Nebraska | Yes |
| Physical and occupational therapy – rehabilitation | Ancillary Services | CoOportunity Health Iowa Nebraska | Yes |
| Pleural effusion drainage systems | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Pneumatic compression device (e.g., Flexitouch) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Pneumatic compression device for deep vein thrombosis (DVT) prevention (e.g., SCD Express, ActiveCare+S.F.T.) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Pompe disease enzyme replacement therapy – alglucosidase alfa (Myozyme® and Lumizyme®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Port wine stain treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Portable/unattended/home sleep tests for the diagnosis of obstructive sleep apnea | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Pralatrexate (Folotyn®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Preventive services – Adult | Medical Services Preventive | CoOportunity Health Iowa Nebraska | No |
| Preventive services – children and adolescents | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Private duty aide in hospital or skilled nursing facility (SNF) | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Prolotherapy | Investigational | CoOportunity Health Iowa Nebraska | No |
| Prophylactic mastectomy | Surgery | CoOportunity Health Iowa Nebraska | No |
| Prostate specific antigen (PSA) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Prosthetic and/or stump coverings | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Prosthetic ear/eye | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Prosthetic limb | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Prothrombin time monitoring – home | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Proton beam radiation therapy | Medical Services | CoOportunity Health Iowa Nebraska | Yes |
| Pulmonary rehabilitation | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Punctal plugs | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Quantitative sensory testing | Investigational | CoOportunity Health Iowa Nebraska | No |
| Quick-serter | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Radioactive (Y-90) liver tumor embolization | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Radiofrequency ablation (RFA) for Barrett's esophagus | Surgery | CoOportunity Health Iowa Nebraska | No |
| Radiofrequency ablation/applications | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Radiofrequency ablative (RFA) denervation procedures for chronic facet-mediated neck & back pain | Medical Services Spine | CoOportunity Health Iowa Nebraska | Yes |
| Radium 223 (Xofigo®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Ramucirumab (Cyramza®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Recent Food and Drug Administration (FDA) approved medications coverage policy | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Reconstructive surgery | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Reduction mammoplasty | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Repetitive transcranial magnetic stimulation | Behavioral Health | CoOportunity Health Iowa Nebraska | No |
| Repose® tongue and hyoid suspension system | Surgery | CoOportunity Health Iowa Nebraska | No |
| Respiratory assist device (RAD) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Rhinoplasty and septorhinoplasty | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Rituximab (Rituxan®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Rope and pulley exerciser | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Sacral nerve stimulation for fecal incontinence | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Sacroiliac joint pain treatment procedures | Medical Services Spine | CoOportunity Health Iowa Nebraska | Yes |
| Saline or sterile water | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Scales | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Scar revision/keloids | Surgery | CoOportunity Health Iowa Nebraska | No |
| Seating support orthosis (SSO) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Selective nerve root block for diagnoses of chronic low back pain with radiculopathy | Medical Services Spine | CoOportunity Health Iowa Nebraska | Yes |
| Sex therapy | Behavioral Health | CoOportunity Health Iowa Nebraska | Yes |
| Sexual dysfunction - medical treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Shoes | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Short term treatment of acute psychiatric illness criteria | Behavioral Health | CoOportunity Health Iowa Nebraska | No |
| Shoulder resurfacing | Investigational Surgery Medical Services | CoOportunity Health Iowa Nebraska | No |
| Silicone gel sheeting | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Siltuximab (Sylvant®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Sipuleucel-T (Provenge®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Sitz baths | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Skilled nursing facility | Ancillary Services | CoOportunity Health Iowa Nebraska | Yes |
| Sleep study (polysomnogram) | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Snoring treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Spacers | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Specialty mattress replacement/overlay (group I) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Speech therapy – habilitative | Ancillary Services | CoOportunity Health Iowa Nebraska | Yes |
| Speech therapy – rehabilitative | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Spinal cord stimulator (SCS) | Surgery Spine | CoOportunity Health Iowa Nebraska | Yes |
| Spinal fusion – lumbar | Surgery Spine | CoOportunity Health Iowa Nebraska | Yes |
| Spinal laminectomy | Medical Services Spine Surgery | CoOportunity Health Iowa Nebraska | No |
| Spinal unloading devices | Equipment/Supplies Spine | CoOportunity Health Iowa Nebraska | No |
| Splints – durable (long term) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Splints – supply (short term) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Standing frame/stander | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Stereotactic radiosurgery | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Sterilization | Medical Services Preventive | CoOportunity Health Iowa Nebraska | No |
| Strabismus surgery | Surgery | CoOportunity Health Iowa Nebraska | No |
| Sublingual immunotherapy (SLIT) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Suction machine and catheter | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Sun tanning booths | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Sympathectomy (thoracic) for the treatment of primary hyperhidrosis | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Synagis (palivizumab) injections for respiratory syncytial virus (RSV) prophylaxis - Effective 11/1/14 | Medical Services Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Telavancin (Vibativ®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Telehealth | Administrative | CoOportunity Health Iowa | No |
| Telehealth - Nebraska | Administrative | CoOportunity Health Nebraska | No |
| Temporomandibular disorder (TMD) treatments | Medical Dental | CoOportunity Health Iowa Nebraska | Yes |
| Termination of Pregnancy - Iowa | Medical Services | Iowa | No |
| Termination of Pregnancy - Nebraska | Medical Services | Nebraska | No |
| Tick borne illness laboratory testing | Laboratory | CoOportunity Health Iowa Nebraska | No |
| Tocilizumab (Actemra®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Topical hyperbaric oxygen (THBO) for wound healing | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Tracheostomy supplies | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Traction equipment | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Transanal endoscopic microsurgery | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Transcatheter closure device for heart conditions | Surgery | CoOportunity Health Iowa Nebraska | No |
| Transcutaneous Aortic Valve Replacement (TAVR) | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Transcutaneous electrical joint stimulation devices | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Transcutaneous electrical nerve stimulator (TENS) unit | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Transfer belt | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Transfer board | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Transjugular intrahepatic porto-systemic shunts (TIPS) | Surgery | CoOportunity Health Iowa Nebraska | No |
| Transplants | Transplants | CoOportunity Health Iowa Nebraska | Yes |
| Transurethral balloon dilation of the prostate | Surgery | CoOportunity Health Iowa Nebraska | No |
| Transurethral microwave therapy for the prostate | Surgery | CoOportunity Health Iowa Nebraska | No |
| Transurethral needle ablation (TUNA, PROSTIVA™) for benign prostatic hyperplasia | Surgery | CoOportunity Health Iowa Nebraska | No |
| Trapeze bar – over bed | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Trastuzumab (Herceptin®) | Pharmacy | CoOportunity Health Iowa Nebraska | No |
| Trend event recorder | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Truss | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Tumor chemosensitivity & chemoresistance assays | Investigational | CoOportunity Health Iowa Nebraska | No |
| Tumor markers | Medical Services | CoOportunity Health Iowa Nebraska | Yes |
| Type I Gaucher disease enzyme replacement therapy: imiglucerase (Cerezyme®), velaglucerase (Vpriv®), telaglucerase (Elelyso®) and eliglustat tartrate (Cerdelga®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Ultrasonic therapy for wound care | Investigational | CoOportunity Health Iowa Nebraska | No |
| Upper limb prosthetics | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Urinal | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Urinary incontinence procedural treatments | Surgery | CoOportunity Health Iowa Nebraska | No |
| Urinary supplies | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Ustekinumab (Stelara®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Uterine activity monitoring services | Medical Services | CoOportunity Health Iowa Nebraska | Yes |
| Uterine artery embolization (UAE) | Surgery | CoOportunity Health Iowa Nebraska | No |
| Uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Vacuum erection system | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Vaginal cones or dilators | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Varicose vein procedures | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Vascular endothelial growth factor (VEGF) inhibitors for ophthalmic use: Aflibercept (Eylea®), Ranibizumab (Lucentis®) and Pegaptanib (Macugen®) | Pharmacy | CoOportunity Health Iowa Nebraska | No |
| Vedolizumab (Entyvio®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Ventilator and supplies | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Ventricular assist device (VADs) & Total artificial hearts | Surgery Transplants | CoOportunity Health Iowa Nebraska | Yes |
| Vision care services | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Vision therapy/orthoptics | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Vitrectomy table | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Voice therapy | Medical Services Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Walkers | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Water-induced thermotherapy for benign prostatic hyperplasia | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Wearable cardioverter defibrillator and non-wearable automatic external defibrillator | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Wedges | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Weight loss management - Iowa | Ancillary Services | CoOportunity Health Iowa | No |
| Weight Loss Programs and Surgery - Nebraska | Medical Services Surgery | CoOportunity Health Nebraska | No |
| Weight loss surgery - Iowa | Surgery | CoOportunity Health Iowa | Yes |
| Weight loss surgery – re-operations - Iowa | Surgery | CoOportunity Health Iowa | Yes |
| Wheelchairs – mobility assistive equipment (MAE) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Wigs/hair prosthesis | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Ziv-aflibercept (Zaltrap®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
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CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.