CurrentQualChoicePolicy N/A

Procedure determinations by clinical category (Approvals/Denials)

Lists multiple procedure categories (e.g., Diagnostic Radiology, Ear Nose and Throat, Home Equipment and Home Services, Hospital Admission, Hospice, etc.) with associated clinical indication categories and a determination of Approved or Denied and a reason for denial when applicable. This part enumerates many indication–procedure pairs with determinations.

Policy Summary

PayerQualChoice

PolicyProcedure determinations by clinical category (Approvals/Denials)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDocument and use the recorded prior authorization determination (Approved or Denied) and, if denied, the reason 'Not Medically Necessary' where provided for claims and appeals.

POLICY UPDATE CHANGES

No material clinical or coverage changes recorded in this brief; the document enumerates prior-authorization determinations by procedure and indication (Approved or Denied) but does not introduce a new policy change.

Q1 2025Reporting period

manyApproved determinations

fewDenied determinations

multipleProcedure–Indication pairs listed

Approved

Typical determination

Coverage summary & scope

This fragment lists multiple procedure categories (for example: Diagnostic Radiology, Ear Nose and Throat, Home Equipment and Home Services, Hospital Admission, Hospice, and others) mapped to clinical indication groupings and a prior-authorization determination for Q1 2025. Determinations recorded in the table are either Approved or Denied and some denied entries include a specific reason.

The coverage stance in this part is mixed: the majority of listed procedure–indication pairs are recorded as Approved, while a smaller number are recorded as Denied — denials in this fragment are typically labeled Not Medically Necessary (and occasionally other denial reasons appear).

Procedure determinations by indication

Procedure determinations

Each entry represents a procedure category with an associated clinical indication and determination:

Diagnostic Radiology; Indication = Factors Influencing Health Status; Determination = Approved; Reason for Denial = N/A

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

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

Ear Nose and Throat; Indication = Nervous System; Determination = Denied; Reason for Denial = Not Medically Necessary

Ear Nose and Throat; Indication = Nervous System; Determination = Approved; Reason for Denial = N/A

Ear Nose and Throat; Indication = Factors Influencing Health Status; Determination = Approved; Reason for Denial = N/A

Family Practice; Indication = Factors Influencing Health Status; Determination = Approved; Reason for Denial = N/A

Hematology/Oncology; Indication = Blood and Blood Forming Organs; Determination = Approved; Reason for Denial = N/A

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

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

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

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

Home Equipment and Home Services; Indication = Hepatobiliary System; Determination = Approved; Reason for Denial = N/A

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

Home Equipment and Home Services; Indication = Endocrine, Nutritional and Metabolic; Determination = Approved; Reason for Denial = N/A

Home Equipment and Home Services; Indication = Musculoskeletal System; Determination = Approved; Reason for Denial = N/A

Home Equipment and Home Services; Indication = Newborns and other Neonates; Determination = Approved; Reason for Denial = N/A

Home Equipment and Home Services; Indication = Myeloproliferative and Neoplasms; Determination = Approved; Reason for Denial = N/A

Home Equipment and Home Services; Indication = Infectious and Parasitic Diseases; Determination = Approved; Reason for Denial = N/A

Home Equipment and Home Services; Indication = Kidney and Urinary Tract; Determination = Approved; Reason for Denial = N/A

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

Hospital admission determination entries

Admission Determination Entries

Each entry records a hospital admission prior authorization determination for a clinical indication with possible reason for denial.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Musculoskeletal System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

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

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

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Circulatory System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Provider actions & documentation

Documentation Required

Prior authorization determinations recorded by indication

The payer records prior-authorization determinations for hospital admissions by clinical indication (e.g., Musculoskeletal System; Pregnancy, Childbirth and Puerperium; Alcohol/Drug Use and Disorders), and notes Approved or Denied with Reason for Denial when applicable.

Documentation Required

Record prior authorization determination

Document and use the recorded prior authorization determination (Approved or Denied) and, if denied, the reason 'Not Medically Necessary' where provided for claims and appeals.

Use recorded determination and denial reason (e.g., 'Not Medically Necessary') when submitting claims or filing appeals.

Definitions

Hospital Admission, Indication: Clinical category or system-level diagnosis associated with the admission request (e.g., Musculoskeletal System; Respiratory System; Mental Illness).

Hospital Admission, Determination: Payer decision on the prior authorization request (Approved or Denied).

Hospital Admission, Reason for Denial: When Denied, typically recorded as 'Not Medically Necessary' in this fragment.

Background

This policy part enumerates determination outcomes (Approved or Denied) across a range of procedure categories and grouped clinical indications. Each entry records a procedure category, the clinical indication, the prior-authorization determination, and, when applicable, a reason for denial.

When denials are present in the listing they are recorded as Not Medically Necessary (with occasional other denial labels noted elsewhere in the full policy).

Coding

No specific billing or CPT/ICD code lists are provided in this fragment; consult the full policy document for complete code groupings and billing code references.

Revision history

Q1 2025statusLatest

CURRENT — This fragment records prior-authorization determinations for multiple procedure categories by clinical indication for the First Quarter 2025 reporting period. Entries list determinations as Approved for the majority of procedure–indication pairs (examples: Diagnostic Radiology, Ear/Nose/Throat, Home Equipment and Home Services, Hospice, Hospital Admission across many indications) with select Denied entries where the reason is recorded as 'Not Medically Necessary' (examples: Hospital Admission — Alcohol/Drug Use and Disorders; Hospital Admission — Mental Illness; Home Equipment and Home Services — Alcohol/Drug Use and Disorders; other select indications). The document may be used to audit or inform submission practices.

Policy Summary

PayerQualChoice

PolicyProcedure determinations by clinical category (Approvals/Denials)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDocument and use the recorded prior authorization determination (Approved or Denied) and, if denied, the reason 'Not Medically Necessary' where provided for claims and appeals.

On This Page

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

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Alcohol/Drug Use and Disorders. Hospital Admission, Determination = Approved or Denied depending on entry (multiple entries). When Denied: Hospital Admission, Reason for Denial = Not Medically Necessary.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Kidney and Urinary Tract. Hospital Admission, Determination = Approved (one entry) and Denied (other entries). When Denied: Hospital Admission, Reason for Denial = Not Medically Necessary.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Digestive System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Mental Illness. Hospital Admission, Determination = Approved or Denied depending on entry (multiple entries). When Denied: Hospital Admission, Reason for Denial = Not Medically Necessary.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Nervous System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Myeloproliferative and Neoplasms. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Skin Subcutaneous Tissue and Breast. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Newborns and other Neonates. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Hepatobiliary System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Respiratory System. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Eye. Hospital Admission, Determination = Approved. Hospital Admission, Reason for Denial = N/A.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Endocrine, Nutritional and Metabolic. Hospital Admission, Determination = Approved or Denied depending on entry; when Denied: Reason for Denial = Not Medically Necessary.

Hospital Admission, Procedure = Hospital Admission. Hospital Admission, Indication = Blood and Blood Forming Organs. Hospital Admission, Determination = Approved or Denied depending on entry; when Denied: Reason for Denial = Not Medically Necessary.

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

Documentation Required

Review prior authorization determinations

Providers should reference prior authorization determinations by procedure category and clinical indication; this document records approvals and denials (with reasons: Not Medically Necessary or Non Covered Benefit) for Q1 2025 and may be used to audit or inform submission practices.

Covers First Quarter 2025 — use to audit or inform submission practices.