Services Reviewed Using InterQual Criteria
Customize your policy alerts
Sign up for phccalifornia Policy CG-UM-002 alerts
Get alerted when Policy CG-UM-002 changes without checking for updates manually.
Monitor payer policy activity
This policy identifies medical, behavioral health, rehabilitation, durable medical equipment, imaging, procedures, specialty pharmacy, and post-acute services that the Health Plan may review for medical necessity using InterQual criteria when Medicare coverage criteria are not fully established. Coverage remains subject to member eligibility, benefit limits, and applicable authorization processes.
Rehabilitative services were added to the services reviewed using InterQual criteria and are considered medically necessary when applicable criteria are met.
Durable medical equipment and procedure services were added to InterQual medical-necessity review for dates of service on or after July 2, 2020.
Negative Pressure Wound Therapy, Capsule Endoscopy, Total Ankle Replacement, and Electroconvulsive Therapy were added to the listed InterQual services effective January 6, 2023.
Cardiac Defibrillator, Subcutaneous Implantable, Home Oxygen Therapy, and Spinal Orthosis were added to the services reviewed using InterQual criteria.
Endovascular Repair for Abdominal Aortic Aneurysm and Prophylactic Total or Simple Mastectomy were added to replace the corresponding prior policies.
Digital Breast Tomosynthesis was added to the InterQual service list to replace policy 6.01.526 effective December 7, 2023.
The Imaging service module was corrected to Imaging, Breast, and the spinal module was corrected to Orthosis, Spinal (Thoracolumbosacral).
When InterQual Criteria Apply
When InterQual Criteria May Be Used
When Medicare coverage criteria are not fully established in statute or regulation, including applicable National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs), the Health Plan may use alternative evidence-based criteria to review services for medical necessity.
Required circumstances and review basis
- Coverage criteria are not fully established in Medicare statute or regulation, including applicable National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs).
The review may use one or more of the following evidence-based sources
- Alternative evidence-based coverage criteria, including InterQual guidelines.
- Applicable treatment guidelines.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.