CurrentPremera BluecrossPolicy N/A

Services Reviewed Using InterQual Criteria

This administrative guideline governs when the Plan uses InterQual evidence-based criteria to review medical and behavioral health services (including procedures, DME, specialty pharmacy, and levels of care) for medical necessity. It informs providers and applies to the Plan's individual member plans.

Policy Summary

PayerPremera Bluecross

PolicyServices Reviewed Using InterQual Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec: 5, 2024

Next Review Date

Key ActionUse the applicable InterQual module criteria when requesting coverage for listed services to support medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyInterQual modules listed

12/13/2024Last revised

Individual plansApplies to

Coverage Criteria — When InterQual Is Used

General medical necessity coverage rule

Covered when InterQual criteria for the specific module are met.

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InterQual module match: Service is considered medically necessary when the applicable InterQual module criteria for that service or condition are met.

Multiple InterQual modules may apply (for example: Acute Adult, Acute Pediatrics, Behavioral Health, Durable Medical Equipment, Procedures, Monitoring, Rehabilitation, Specialty Pharmacy, etc.). Use the specific InterQual module relevant to the service under review.

Certain services previously reviewed under this InterQual guideline have been removed from the scope of review. Notably, Imaging; breast was removed from review effective following the 09/01/24 annual update (approved August 13, 2024). Earlier updates removed selected outpatient procedures and durable medical equipment from the InterQual review list (changes announced in 2020 with an effective date of February 5, 2021). The policy history documents additional periodic additions and removals to the modules under review and notes that module membership has changed over time.

Services that do not meet the applicable InterQual medical necessity criteria for the relevant InterQual module are not considered medically necessary for coverage purposes and may be denied under the Plan’s review process. Providers should anticipate that review determinations follow the InterQual module criteria applicable to the service or level of care under review.

Coding — What Codes Are Listed

No CPT/HCPCS/ICD codes providedmixed

No codes listed

Provider Actions What Providers Must Do

Prior Authorization

InterQual-based review required for listed services — Plan uses InterQual criteria across multiple modules

InterQual-based review is required for the services and modules listed in this guideline. The Plan uses InterQual criteria (across applicable modules) to determine medical necessity; services that do not meet InterQual criteria may be denied per the Plan review process.

InterQual is used across multiple modules (e.g., acute care, procedures, DME, specialty pharmacy, rehabilitation, LTAC).
Services reviewed under InterQual include specialty drugs and oncology agents listed in the guideline; see Specialty Rx and Specialty Rx Oncology modules for specific agents.
When InterQual criteria are not met, prior authorization requests or claims for the service may be denied in accordance with the Plan review process.

Prior Authorization

Specialty drug review via InterQual — certain specialty and oncology drugs included in modules reviewed

Certain specialty and oncology drugs included in the guideline are reviewed under InterQual specialty pharmacy modules. Providers must submit clinical documentation that supports InterQual medical necessity criteria for these agents.

Examples of specialty agents covered by InterQual review include (but are not limited to): lanreotide, octreotide, hydroxyprogesterone caproate, bevacizumab intravitreal, and various clotting factor products.
Ensure drug-specific clinical details (diagnosis, prior therapies, dosing history, relevant lab results) are provided to support review.

Documentation Required

Documentation and member benefits — consult member benefit booklets or contact member services; policy is a guide for Company staff

This policy is a guide for Company staff; coverage is subject to the limits and conditions of the member's benefit plan. Providers should consult the member benefit booklet or contact member services to confirm benefit coverage and any plan-specific limitations before rendering services.

Coverage depends on the members specific benefit plan; this guideline does not guarantee coverage.
Contact member services or review the member benefit booklet to verify eligibility, benefits, and any required preauthorization or network requirements.

Denial Risk

Denial risk when InterQual criteria not met — services failing criteria may be denied per Plan review process

Services that fail to meet applicable InterQual criteria may be denied. Providers should be aware of denial risk and ensure submissions include all required documentation to demonstrate medical necessity per InterQual.

Incomplete documentation or failure to meet InterQual criteria increases the likelihood of denial.
Prior authorization does not guarantee payment if documentation does not support medical necessity under InterQual.

Background — About InterQual

InterQual is an evidence-based set of clinical criteria used to evaluate medical necessity across a wide range of services and levels of care, including acute care (adult and pediatric), procedures, durable medical equipment, monitoring, rehabilitation, care planning, complex care management, and specialty pharmacy. The Plan uses the specified InterQual modules listed in this guideline to determine when a particular service or level of care meets medical necessity criteria.

Definitions

InterQual — definition and purpose

DefinitionInterQual: evidence-based clinical criteria used to guide coverage decisions for medical and behavioral health services, levels of care, care planning, complex care management, durable medical equipment, procedures, and specialty pharmacy.

PurposeProvides standardized, evidence-based guidance to determine medical necessity across multiple service types and levels of care.

Use in review processThe Plan uses InterQual to review certain services for medical necessity as listed in this guideline.

AudienceIntended for providers and Company staff as a resource when evaluating coverage and medical necessity.

Scope and applicability

Applies toThis medical policy applies to Individual plans only.

Policy roleServes as a guide for Company staff when determining coverage for specific services; it is not a guarantee of benefits.

Member contract precedenceCoverage for medical services is subject to the limits and conditions of the member benefit plan; members and providers should consult the member benefit booklet or contact customer service for benefit limitations.

Provider guidanceThe guideline informs providers about when a service may be covered and how InterQual criteria are applied in the Plan's review process.

Revision History

2024-12-13revisionLatest

Minor correction made to format

2024-12-05effective_date

Policy effective date set to Dec 5, 2024

2024-09-01annual_review

Annual review approved Aug 13, 2024; imaging (breast) removed from review and multiple subsets added for 90-day notification

2024-01-01interim_review

Interim review (approved Dec 12, 2023) with additions to Procedures section including salpingo-oophorectomy and related procedures