| Genetic Testing: Oncology Testing: Hereditary Cancer | Effective Jul 1, 2026 · Commercial, Medicaid | 63 | Original policy ↗ |
| Genetic Testing: Specialty Testing: Endocrinology | Effective Jul 1, 2026 · Commercial, Medicaid | 6 | Original policy ↗ |
| Genetic Testing: Specialty Testing: Hematology | Effective Jul 1, 2026 · Commercial, Medicaid | 23 | Original policy ↗ |
| Genetic Testing: Specialty Testing: Immunology and Rheumatology | Effective Jul 1, 2026 · Commercial, Medicaid | 36 | Original policy ↗ |
| Genetic Testing: Specialty Testing: Nutrition and Metabolism | Effective Jul 1, 2026 · Commercial, Medicaid | 11 | Original policy ↗ |
| Glaucoma Surgical Treatments | Effective Jul 1, 2026 · Commercial, Medicaid | 7 | Original policy ↗ |
| Global Days | RP-P-170X · Effective Apr 1, 1999 · Commercial, Medicaid | 2 | Original policy ↗ |
| Hair Analysis in the Clinical Setting | Effective May 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| High Intensity Focused Ultrasound (HIFU) and Magnetic Resonance Guided Focused Ultrasound (MRgFUS) | Effective Jun 1, 2026 · Commercial, Medicaid | 10 | Original policy ↗ |
| Home Birth Services – Minnesota Medical Assistance Members CP5212 | CP5212 · Effective Apr 1, 2026 · Medicaid | 35 | Original policy ↗ |
| Home Traction Devices, Cervical and Lumbar | Effective Oct 1, 2025 · Commercial, Medicaid | 11 | Original policy ↗ |
| Home Use of Bilevel Positive Airway Pressure (BiPAP) for Conditions Other Than Obstructive Sleep Apnea (OSA) | Effective Aug 1, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Home Use of Continuous Positive Airway Pressure (CPAP)) and Bilevel Positive Airway Pressure (BiPAP) | Commercial, Medicaid | 3 | Original policy ↗ |
| Hospital Based Clinics | RP-X-123X · Effective Aug 1, 2014 · Commercial, Medicaid | 3 | Original policy ↗ |
| Hyperbaric and Topical Oxygen Therapy | Effective Oct 1, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| i-FACTOR™ Bone Graft | Effective Jan 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Image-Guided Superficial Radiotherapy (IG-SRT) | Effective Aug 1, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Implanted Peripheral Nerve Stimulators for Treatment of Pain | Effective Nov 1, 2025 · Commercial, Medicaid | 3 | Original policy ↗ |
| In Vitro Chemosensitivity and Chemoresistance Assays | Effective Nov 1, 2025 · Commercial, Medicaid | 2 | Original policy ↗ |
| Inappropriate Primary Diagnosis | RP-P-180X · Effective Jun 22, 2013 · Commercial, Medicaid | — | Original policy ↗ |
| Increased Procedural Services | RP-P-185X · Effective Jan 1, 2001 · Commercial, Medicaid | 2 | Original policy ↗ |
| Incremental Nursing | RP-F-190X · Effective Nov 1, 2012 · Commercial, Medicaid | — | Original policy ↗ |
| Infertility Services | Effective Nov 1, 2025 · Commercial, Medicaid | — | Original policy ↗ |
| Inhaled Nitric Oxide (iNO) Therapy | Effective Dec 1, 2025 · Commercial, Medicaid | — | Original policy ↗ |
| Initial Inpatient Consultation Policy | Effective Mar 1, 1997 · Commercial, Medicaid | 10 | Original policy ↗ |
| Injection and Infusion Services | RP-P-200X · Effective Jan 1, 1996 · Commercial, Medicaid | 8 | Original policy ↗ |
| Inpatient Hospital Readmission | Commercial, Medicaid | — | Original policy ↗ |
| Intense Pulsed Light Treatment for Dry Eye Disease | Effective Jun 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Intensity Modulated Radiation Therapy (IMRT) Planning | RP-F-210X · Effective Jun 15, 2016 · Commercial, Medicaid | 4 | Original policy ↗ |
| Interferential Current Stimulation | Effective Oct 1, 2025 · Commercial, Medicaid | 3 | Original policy ↗ |
| Intraoperative Neurological Monitoring (IONM) | RP-P-220X · Effective Jul 1, 2019 · Commercial, Medicaid | 3 | Original policy ↗ |
| Intraoperative Neurophysiologic Monitoring (IONM) | Effective Oct 1, 2025 · Commercial, Medicaid | 3 | Original policy ↗ |
| Intravascular Shockwave Lithotripsy for Treatment of Coronary Artery Disease | Effective Oct 1, 2025 · Commercial, Medicaid | 2 | Original policy ↗ |
| Intravenous, Intramuscular, and Subcutaneous Ketamine for Chronic Pain, Mental Health and Substance Use Disorders | Effective Sep 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| IpsiHand Upper Extremity Rehabilitation System | Effective May 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Iris Prosthesis (Artificial Iris Devices. E.g., CustomFlex™) | Effective Jul 1, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Irreversible Electroporation (NanoKnife® System) | Effective Dec 21, 2020 · Commercial, Medicaid | 2 | Original policy ↗ |
| Irreversible Electroporation (NanoKnife® System) | Effective Dec 21, 2020 · Commercial, Medicaid | 2 | Original policy ↗ |
| Laboratory Service | RP-P-170X · Effective Jun 23, 1999 · Commercial, Medicaid | 13 | Original policy ↗ |
| Laboratory Tests | Effective Jul 1, 2025 · Commercial, Medicaid | — | Original policy ↗ |
| Laser Spine Surgeries | Effective Oct 1, 2025 · Commercial, Medicaid | — | Original policy ↗ |
| Laser Therapy for Nicotine Dependence | Effective Jan 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Laser Therapy for Treatment of Pain | Effective Apr 1, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Light Treatment and Laser Therapies for Benign Dermatologic Conditions | Effective Sep 1, 2026 · Commercial, Medicaid | 13 | Original policy ↗ |
| Lipoprotein Subclass Testing for Screening, Evaluation, and Monitoring of Cardiovascular Disease | Effective Jul 1, 2026 · Commercial, Medicaid | 6 | Original policy ↗ |
| Lipoprotein-associated Phospholipase A2 (Lp-PLA2) Immunoassay for Prediction of Risk for Coronary Heart Disease or Ischemic Stroke (PLAC® Test) | Effective Jun 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Liposuction for Lymphedema or Lipedema | Effective Jul 1, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Maximum Units of Service (MUS) | RP-P-230X · Commercial, Medicaid | — | Original policy ↗ |
| Maximum Units of Service (MUS) - Facility | RP-F-565M · Effective Mar 1, 2023 · Commercial, Medicaid | — | Original policy ↗ |
| Mechanical Circulatory Support Devices | Effective Jan 15, 2024 · Commercial, Medicaid | 20 | Original policy ↗ |
