CurrentQualChoicePolicy N/A

Procedure determinations by specialty and indication

This document lists determinations (Approved or Denied) and reasons for denial for numerous procedure categories mapped to clinical indication groupings; it is a matrix of coverage determinations for procedure/indication pairs.

Policy Summary

PayerQualChoice

PolicyProcedure determinations by specialty and indication

Policy CodePolicy N/A

Change TypeInformational Q4 2024 reporting

Effective DateN/A

Next Review DateN/A

Key ActionProviders and billing staff should reference the procedure/indication determination entries when submitting claims and include clinical documentation supporting the indicated procedure for review.

POLICY UPDATE CHANGES

No material clinical or coverage changes in this document — informational Q4 2024 prior authorization determinations by procedure and indication.

multipleApproved determinations listed

someDenied determinations listed

Q4 2024Reporting period

mixedDeterminations mix

Not Medically NecessaryCommon denial reason

MultipleProcedures included

Coverage Summary

This part of the document is a procedure/indication determination matrix reporting discrete determinations (Approved or Denied) for many procedure categories mapped to clinical indication groupings for Q4 2024; entries record Procedure = , Indication = , Determination = , and Reason for Denial when applicable.

Headline statistics

Reporting periodQ4 2024

Coverage stancemixed (majority approved but some denials)

Approved determinationsFrequent approvals across many procedures and indications

Denied determinationsSome denials present (e.g., Not Medically Necessary, Non Covered Benefit)

Common denial reasonNot Medically Necessary

Indications reportedMultiple clinical categories (e.g., Circulatory, Musculoskeletal, Alcohol/Drug Use)

Procedure / Indication Determinations (matrix)

Procedure/Indication Determinations

Each entry is a discrete determination for a Procedure = <specialty/procedure> and Indication = <clinical grouping>.

ANY of the following

Cardiac Surgery; Indication = Circulatory System; Determination = Approved; Reason for Denial = N/A
Cardiology Medical; Indication = Circulatory System; Determination = Approved; Reason for Denial = N/A
Diagnostic Radiology; Indication = Circulatory System; Determination = Approved; Reason for Denial = N/A
Ear Nose & Throat; Indication = Ear, Nose, and Throat; Determination = Approved; Reason for Denial = N/A

Denials and Non‑Covered Determinations

Denials in the extract commonly cite Not Medically Necessary and Non Covered Benefit as reasons. Clinical indication categories with noted denials include Alcohol/Drug Use and Disorders, Digestive, Musculoskeletal, Nervous, and Circulatory (among others).

Coding

No procedure or diagnosis codes listed in this partmixed

No codes listed

Provider Actions

Documentation Required

Use of determination matrix for adjudication

Providers and billing staff should reference the procedure/indication determination entries when submitting claims to determine if a given procedure/indication pair is Approved or Denied and include clinical documentation supporting the indicated procedure for review.

Documentation Required

Use of Prior Authorization determinations for care planning

This document is informational Q4 2024 reporting of prior authorization determinations by indication; providers should reference applicable QualChoice prior authorization policy/policy number for clinical submission and denial reason details.

Background

This part of the document contains a repetitive listing of procedure types paired with a clinical indication groupings and a short coverage determination (Approved or Denied) plus an optional reason for denial. It appears to be a machine-exported or templated portion of a larger coverage matrix.

Policy Summary

PayerQualChoice

PolicyProcedure determinations by specialty and indication

Policy CodePolicy N/A

Change TypeInformational Q4 2024 reporting

Effective DateN/A

Next Review DateN/A

On This Page

Ear Nose & Throat; Indication = Eye; Determination = Approved; Reason for Denial = N/A

Ear Nose & Throat; Indication = Ear, Nose, and Throat; Determination = Denied; Reason for Denial = Not Medically Necessary

Emergency; Indication = Digestive System; Determination = Approved; Reason for Denial = N/A

Emergency; Indication = Nervous System; Determination = Approved; Reason for Denial = N/A

Emergency; Indication = Musculosketal System; Determination = Approved; Reason for Denial = N/A

Emergency; Indication = Circulatory System; Determination = Approved; Reason for Denial = N/A

Family Practice; Indication = Circulatory System; Determination = Approved; Reason for Denial = N/A

Family Practice; Indication = Nervous System; Determination = Approved; Reason for Denial = N/A

Hematology/Oncology; Indication = Respiratory System; Determination = Approved; Reason for Denial = N/A

Hematology/Oncology; Indication = Factors Influencing Health Status; Determination = Approved; Reason for Denial = N/A

Hematology/Oncology; Indication = Skin Subcutaneous Tissue and Breast; Determination = Approved; Reason for Denial = N/A

Hematology/Oncology; Indication = Male Reproductive System; Determination = Approved; Reason for Denial = N/A

Home Equipment & Home Services; Indication = Alcohol/Drug Use and Disorders; Determination = Approved; Reason for Denial = N/A

Home Equipment & Home Services; Indication = Musculosketal System; Determination = Denied; Reason for Denial = Not Medically Necessary

Home Equipment & Home Services; Indication = Respiratory System; Determination = Approved; Reason for Denial = N/A

Home Equipment & Home Services; Indication = Endocrine, Nutritional and Metabolic; Determination = Denied; Reason for Denial = Non Covered Benefit

Home Equipment & Home Services; Indication = Digestive System; Determination = Approved; Reason for Denial = N/A

Home Equipment & Home Services; Indication = Nervous System; Determination = Approved; Reason for Denial = N/A

Home Equipment & Home Services; Indication = Injuries, Poisonings and Drug Effects; Determination = Approved; Reason for Denial = N/A

Home Equipment & Home Services; Indication = Factors Influencing Health Status; Determination = Approved; Reason for Denial = N/A

Home Equipment & Home Services; Indication = Skin Subcutaneous Tissue and Breast; Determination = Approved; Reason for Denial = N/A

Home Equipment & Home Services; Indication = Myeloproliferative and Neoplasms; Determination = Denied; Reason for Denial = Not Medically Necessary

Hospital Admission; Indication = Factors Influencing Health Status; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Alcohol/Drug Use and Disorders; Determination = Denied; Reason for Denial = Not Medically Necessary

Hospital Admission; Indication = Pregnancy, Childbirth and Puerperium; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Musculosketal System; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Ear, Nose, and Throat; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Kidney and Urinary Tract; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Respiratory System; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Digestive System; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Hepatobilary System; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Female Reproductive System; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Nervous System; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Blood and Blood Forming Organs; Determination = Approved; Reason for Denial = N/A

Hospital Admission; Indication = Infectious and Parasitic Diseases; Determination = Approved; Reason for Denial = N/A

Prior Authorization Determinations (Q4 2024) by Indication

Each entry records a Hospital Admission determination for a given ICD-CC / clinical indication with determination and reason for denial when applicable.

ANY of the following

Hospital Admission, Indication = Factors Influencing Health Status. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Circulatory System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Digestive System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Musculosketal System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Blood and Blood Forming Organs. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Pregnancy, Childbirth and Puerperium. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Respiratory System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Female Reproductive System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Endocrine, Nutritional and Metabolic. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Nervous System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Infectious and Parasitic Diseases. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Myeloproliferative and Neoplasms. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Skin Subcutaneous Tissue and Breast. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Kidney and Urinary Tract. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Ear, Nose, and Throat. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Newborns and other Neonates. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Alcohol/Drug Use and Disorders. Hospital Admission, Determination = Approved OR Denied (mixed entries within quarter). When Denied: Reason for Denial = Not Medically Necessary.
Hospital Admission, Indication = Female Reproductive System. Hospital Admission, Determination = Denied. Hospital Admission, Reason for Denial = Not Medically Necessary.
Hospital Admission, Indication = Factors Influencing Health Status. Hospital Admission, Determination = Denied. Hospital Admission, Reason for Denial = Not Medically Necessary.
Hospital Admission, Indication = Musculosketal System. Hospital Admission, Determination = Denied. Hospital Admission, Reason for Denial = Not Medically Necessary.
Hospital Admission, Indication = Respiratory System. Hospital Admission, Determination = Denied. Hospital Admission, Reason for Denial = Not Medically Necessary.
Hospital Admission, Indication = Mental Illness. Hospital Admission, Determination = Denied (some entries). Hospital Admission, Reason for Denial = Not Medically Necessary.
Hospital Admission, Indication = Injuries, Poisonings and Drug Effects. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Eye. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.
Hospital Admission, Indication = Male Reproductive System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Prior Authorization Determinations by Indication

Each record: Hospital Admission, Indication = <clinical category>. Hospital Admission, Determination = <Approved|Denied>. Hospital Admission, Reason for Denial = <text or N/A>.

ANY of the following

Hospital Admission, Indication = Digestive System; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Female Reproductive System; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Nervous System; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Musculosketal System; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Pregnancy, Childbirth and Puerperium; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Infectious and Parasitic Diseases; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Skin Subcutaneous Tissue and Breast; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Alcohol/Drug Use and Disorders; Hospital Admission, Determination = Denied; Hospital Admission, Reason for Denial = Not Medically Necessary
Hospital Admission, Indication = Kidney and Urinary Tract; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Respiratory System; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Myeloproliferative and Neoplasms; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Factors Influencing Health Status; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Newborns and other Neonates; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Ear, Nose, and Throat; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Endocrine, Nutritional and Metabolic; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Circulatory System; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Injuries, Poisonings and Drug Effects; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Mental Illness; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Eye; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Hepatobilary System; Hospital Admission, Determination = Approved; Hospital Admission, Reason for Denial = N/A
Hospital Admission, Indication = Digestive System; Hospital Admission, Determination = Denied; Hospital Admission, Reason for Denial = Not Medically Necessary
Hospital Admission, Indication = Musculosketal System; Hospital Admission, Determination = Denied; Hospital Admission, Reason for Denial = Not Medically Necessary
Hospital Admission, Indication = Nervous System; Hospital Admission, Determination = Denied; Hospital Admission, Reason for Denial = Not Medically Necessary
Hospital Admission, Indication = Circulatory System; Hospital Admission, Determination = Denied; Hospital Admission, Reason for Denial = Not Medically Necessary

Documentation Required

Use prior authorization statistics for review and audit

This document is informational; providers should review authorization determinations and denial reasons (e.g., 'Not Medically Necessary') for quality, appeals, or process improvement; no new prior authorization requirements are specified in this part.

Note

Prior authorization outcome reporting (informational)

This document is an informational summary of prior authorization determinations by procedure and indication for Q4 2024; it does not impose new clinical prior authorization requirements or billing rules.