Services Reviewed Using InterQual Criteria
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Identifies medical, behavioral health, rehabilitation, durable medical equipment, home care, imaging, long-term acute care, procedural, and specialty pharmacy services that may be reviewed for medical necessity using InterQual criteria when Medi-Cal coverage criteria are not fully established; member eligibility and benefit limitations apply.
Rehabilitative services were added to the services reviewed using InterQual criteria and were described as medically necessary when applicable criteria are met.
Durable medical equipment and procedure services were added to the services reviewed for medical necessity using InterQual criteria.
Outpatient procedures and durable medical equipment were removed from the policy effective February 5, 2021 pursuant to provider notification.
Negative pressure wound therapy, capsule endoscopy, total ankle replacement, and electroconvulsive therapy were added to the InterQual review list.
Home oxygen therapy, subcutaneous cardiac defibrillator-related review, and spinal orthosis were added to the services reviewed using InterQual criteria.
Endovascular repair of abdominal aortic aneurysm and prophylactic total or simple mastectomy were added to replace prior policies addressing those services.
Digital breast tomosynthesis was added to the InterQual review list to replace the prior digital breast tomosynthesis policy.
Botulinum toxins were removed from the specialty pharmacy section and assigned to a separate botulinum toxins policy.
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