ModifiedDevoted HealthPolicy MM.73

InterQual Prior Authorization Medical Necessity Criteria

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Services and procedures on Devoted Health's prior authorization list are reviewed for medical necessity using applicable InterQual Medicare or level-of-care criteria for Devoted Medicare Advantage members.

Policy Summary

PayerDevoted Health

PolicyInterQual Prior Authorization Medical Necessity Criteria

Policy CodePolicy MM.73

Change TypeModified

Effective DateN/A

Last ReviewJan 12, 2026

Next Review DateJan 15, 2027

Key ActionReview listed services and procedures for medical necessity using the applicable InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

Behavioral health services were added to the policy effective January 1, 2026.

5Medicare InterQual service subsets

> $750DME allowable amount threshold

2–3Inpatient and post-acute updates per year

March/AprilAnnual update timing

01/01/2026Behavioral health effective date

Policy Summary

PayerDevoted Health

PolicyInterQual Prior Authorization Medical Necessity Criteria

Policy CodePolicy MM.73

Change TypeModified

Effective DateN/A

Last ReviewJan 12, 2026

Next Review DateJan 15, 2027

Key ActionReview listed services and procedures for medical necessity using the applicable InterQual criteria.

SourceLink

On This Page

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ModifiedDevoted HealthPolicy MM.73

InterQual Prior Authorization Medical Necessity Criteria

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Get alerted when Policy MM.73 changes without checking for updates manually.

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Policy Summary

PayerDevoted Health

PolicyInterQual Prior Authorization Medical Necessity Criteria

Policy CodePolicy MM.73

Change TypeModified

Effective DateN/A

Last ReviewJan 12, 2026

Next Review DateJan 15, 2027

Key ActionReview listed services and procedures for medical necessity using the applicable InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

Behavioral health services were added to the policy effective January 1, 2026.

5Medicare InterQual service subsets

> $750DME allowable amount threshold

2–3Inpatient and post-acute updates per year

March/AprilAnnual update timing

01/01/2026Behavioral health effective date

Policy Summary

PayerDevoted Health

PolicyInterQual Prior Authorization Medical Necessity Criteria

Policy CodePolicy MM.73

Change TypeModified

Effective DateN/A

Last ReviewJan 12, 2026

Next Review DateJan 15, 2027

Key ActionReview listed services and procedures for medical necessity using the applicable InterQual criteria.

SourceLink

On This Page

Medical Necessity Review

General medical-necessity review

Covered when the applicable InterQual criteria are met.

Applicable InterQual medical-necessity criteria: The service or procedure is included on Devoted Health's prior authorization list and satisfies the applicable InterQual criteria for the relevant service category or level of care.

For services without applicable InterQual criteria, use applicable Medicare guidance, including National Coverage Determinations or Local Coverage Determinations where specified.

Prior Authorization and Review Requirements

Prior Authorization

InterQual Medical-Necessity Review Required

Devoted Health uses evidence-based InterQual criteria to review the services and procedures listed below for medical necessity. Providers should submit the applicable clinical information for prior authorization and medical-necessity review; the Medicare subsets are based on applicable NCDs and LCDs.

InterQual Medicare subsets apply to Imaging, Molecular Diagnostics & Lab, Pharmacy, Post Acute & Durable Medical Equipment, and Procedures.
Additional InterQual subsets apply to Acute Inpatient Level of Care, Long-term Acute Care, Inpatient Rehabilitation, and Subacute/Skilled Nursing Facility services.
Services are considered medically necessary when applicable InterQual criteria are met.

Documentation Required

Concurrent Inpatient Level-of-Care Review

During concurrent review, use the Acute Adult Inpatient subsets to determine the appropriate level of care, including observation versus inpatient status. After the level-of-care determination, clinical updates are obtained only for discharge planning and coordination of services.

Acute Adult Inpatient subsets include: Acetaminophen Overdose; Acute Coronary Syndrome; Acute Kidney Injury; Anemia; Antepartum; Arrhythmia, Atrial; Arrhythmia, Blocks; Arrhythmia, Ventricular or Abnormal ECG Findings; Asthma; Bowel Obstruction; Carbon Monoxide Poisoning; COPD; Deep Vein Thrombosis; Diabetes Mellitus; Diabetic Ketoacidosis; Electrolyte or Mineral Imbalance; Epilepsy; Gallbladder Disorders; Gastrointestinal Bleeding; General Medicine; General Surgical; General Trauma; Heart Failure; Hematology/Oncology Complications or Disease Progression; Hematology/Oncology: Hemolytic Uremic Syndrome; Hematology/Oncology: Treatments; Hyperosmolar Hyperglycemic State; Hypertension; Hypertensive Disorders of Pregnancy; Hypoglycemia; Infection: Cellulitis; Infection: CNS; Infection: COVID-19; Infection: Endocarditis; Infection: General; Infection: GI/GYN; Infection: Musculoskeletal; Infection: Pneumonia; Infection: Pyelonephritis or Complex UTI; Infection: Sepsis; Infection: Skin; Inflammatory Bowel Disease; Labor and Delivery; Non-Traumatic Bleeding; Pancreatitis; Postpartum Complication After Discharge; Pulmonary Embolism; Rhabdomyolysis or Crush Syndrome; Sickle Cell Disease; Stroke; Syncope; TIA; and Withdrawal Syndrome.

Prior Authorization

Medicare, Post-Acute, DME, Imaging, Laboratory, and Procedure Categories

Apply the applicable InterQual Medicare and post-acute subsets when requesting authorization for the following service categories. Review requirements include Medicare guidance and, where applicable, NCD/LCD-based criteria.

Medicare Durable Medical Equipment: Bariatric equipment for patients over 300 pounds; bone growth stimulators; custom or specialized wheelchairs and scooters; neuromuscular stimulators; portable oxygen concentrators; prosthetics; specialty beds; Medicare-covered ventilators; wound vacuums; wearable cardiac devices such as LifeVest; external infusion pumps, including insulin pumps; and any other DME item costing more than $750 based on the Medicare allowable amount.
Medicare Imaging: MRA, MRI, PET scan, and SPECT.
Medicare Molecular Diagnostics & Lab: Molecular diagnostics and laboratory services subject to the applicable InterQual Medicare subset.
Long-Term Acute Care (LTACH): Medically complex, respiratory complex, transition plan, ventilator weaning, wound/skin, and negative pressure wound therapy.
Medicare Procedures: Implantable defibrillators; left atrial appendage closure devices; nuclear stress tests; transesophageal echocardiograms; transcatheter valve surgeries, including TAVR; cardiac resynchronization therapy; abdominoplasty; blepharoplasty; breast augmentation procedures; gynecomastia surgery; panniculectomy and redundant skin tightening; rhinoplasty; cochlear and auditory brain implants; gender dysphoria surgery; obesity surgery such as gastric bypass; oral, orthognathic, or temporomandibular joint surgery; hip, knee, and shoulder arthroscopy; total joint replacements; surgery for obstructive sleep apnea; varicose vein surgical treatment and sclerotherapy; facility-based sleep studies; infertility testing and treatment; molecular diagnostic and genetic testing; hyperbaric therapy; epidural injections; facet injections; kyphoplasty; neurostimulators; spinal cord stimulators; spinal decompression surgery; spinal fusion; vertebroplasty; and cataract surgery.

Prior Authorization

Specialty Pharmacy Review

Specialty pharmacy drugs require prior authorization and medical-necessity review under the applicable InterQual pharmacy subset. Submit the drug, indication, and supporting clinical documentation for review.

Specialty RX—Non-oncology: Gammagard liquid; Gammaked; Gamunex-C; Asceniv; Bivigam; Flebogamma 5% and 10%; Gammaplex 5% and 10%; Octagam 5% and 10%; Panzyga; Privigen; Cutaquig; Cuvitru; Hizentra; HyQvia; Xembify; Entyvio; Stelara; Actemra; Orencia; Cimzia; Riabni; Rituxan; Remicade; Renflexis; Nplate; and Botox.
Medicare Pharmacy: Botulinum toxins; intravenous/subcutaneous immune globulin; rituximab; infliximab; and verteporfin.

Prior Authorization

Behavioral Health Services

Behavioral health services are subject to the applicable InterQual review requirements. The behavioral health services listed below were added effective January 1, 2026.

Adult and geriatric psychiatry.
Substance abuse disorders.
Behavioral health services.

Unsupported block type: denial_risk

Documentation Required

NCD/LCD Requirements When No InterQual Criteria Apply

For oral, orthognathic, or temporomandibular joint surgeries, use the applicable Medicare National Coverage Determination or Local Coverage Determination requirements when no applicable InterQual criteria are available.

Apply the relevant NCD/LCD requirements to the procedure and diagnosis.
Include documentation demonstrating that the applicable Medicare coverage requirements are met.

Policy Background

Devoted Health uses evidence-based InterQual criteria to evaluate the medical necessity of services and procedures on its prior authorization list. The criteria support reviews across acute inpatient and post-acute levels of care, durable medical equipment, imaging, molecular diagnostics and laboratory services, pharmacy, procedures, and behavioral health services.

The Medicare InterQual subsets are based on applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), together with Medicare guidance. Devoted implements updates as Medicare guidance changes; inpatient and post-acute level-of-care criteria are updated 2–3 times per year, with the overall annual update typically released in March or April and approved through the Utilization Management Committee.

Coverage Determination Terms

Definitions

NCDNational Coverage Determination

Definitions

LCDLocal Coverage Determination