QualChoice Home Equipment Prior Auth Policy Update

Coverage determinations and patterns

Quarterly determination patterns

Determinations recorded in the quarter are reported by service and clinical indication; outcomes in the source vary by indication with both Approved and Denied entries.

Hospital Admission - Alcohol/Drug Use and Disorders: Some hospital admission requests with indication 'Alcohol/Drug Use and Disorders' were approved in multiple entries while others were denied (reason recorded as 'Not Medically Necessary').

mixed outcomes across reported cases

Internal Medicine - Mental Illness / Alcohol/Drug Use / Factors Influencing Health Status: Internal Medicine requests include Approved and Denied determinations; denied entries list reasons such as 'Not Medically Necessary'.

mixed outcomes across reported cases

Lab - Factors Influencing Health Status / Pregnancy, Childbirth and Puerperium: Lab requests appear as both Approved and Denied; denied lab entries are recorded with reason 'Not Medically Necessary' for indications including Factors Influencing Health Status and Pregnancy/Childbirth/Puerperium.

mixed outcomes

Mental Health - Mental Illness / Alcohol/Drug Use / Test/Evaluation Procedures: Mental Health requests show mixed determinations: approvals for some Alcohol/Drug Use and Disorders entries, and denials for Mental Illness or certain test/evaluation procedure lines (reasons include 'Benefits Exhausted' and 'Not Medically Necessary').

mixed outcomes; includes specific procedure lines in mental health entries

Instances in the Home Equipment & Home Services category recorded as "Non Covered Benefit" indicate those specific requests were excluded from coverage in the reported cases. These entries appear in the Second Quarter 2023 prior authorization dataset and identify particular Home Equipment & Home Services requests as not covered by the benefit plan.

The report documents hospital admission entries during the quarter that were denied with the reason "Non Covered Benefit". These denials indicate the payer determined those specific hospital admission requests were outside covered benefits for the member in the reported cases.

Some Internal Medicine prior authorization records in the quarter were denied and explicitly labeled "Non Covered Benefit", demonstrating that certain Internal Medicine requests or indications were adjudicated as excluded from coverage in those reported instances.

Entries across the dataset list determinations marked "Non Covered Benefit", which the payer used to indicate explicit non‑coverage for particular requests. The report does not list the specific items in every case but records the non‑covered status for those requests.

Some Home Equipment & Home Services prior authorization determinations in the quarter were denied with the reason recorded as "Not Medically Necessary", indicating a clinical‑necessity denial in those reported instances.

The dataset includes hospital admission denials recorded as "Not Medically Necessary" for indications such as Alcohol/Drug Use and Disorders and, in at least one record, for a Nervous System or Respiratory System indication. These entries show medical‑necessity adjudication drove some denials for admissions.

Multiple hospital admission denials in the quarter are recorded with the reason "Not Medically Necessary". The report lists repeated instances across different admission indications where medical necessity was cited as the denial reason.

The prior authorization records show multiple hospital admissions denied for "Not Medically Necessary" across the reporting period. These repeated entries indicate medical‑necessity findings contributed to a number of admission denials.

Several denials in the quarter list "Not Medically Necessary" for a variety of indications, including Alcohol/Drug Use and Disorders and Mental Illness, reflecting that medical‑necessity determinations affected multiple clinical categories.

Across specialties and procedure types reported in the quarter, there are multiple denials recorded with the reason "Not Medically Necessary". These denials span departments such as Mental Health, Pulmonary Medicine and Surgery, indicating medical‑necessity adjudication was applied broadly where recorded.

Procedure descriptors and quoted procedures

Procedure descriptors reportedmixed

PSYCL/NRPSYCL TST PHYS/QHP 2 + TST EA ADDL 30 MIN	Psychological/Non-psychological test by physician/qualified healthcare professional, 2+ tests each, additional 30 minutes
PYCL/NRPSYCL TST TECH 2+ TST EA ADDL 30 MIN	Psychological/Non-psychological test by technician, 2+ tests each, additional 30 minutes
NEUROPSYSCHOLOGICAL TST EVAL PHYS/QHP 1ST HOUR	Neuropsychological test evaluation by physician/qualified healthcare professional, first hour
PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR	Psychological test evaluation service by physician/qualified healthcare professional, each additional hour

Quoted procedure descriptions — 2 codesmixed

PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR	Quoted text from source: Psychological test evaluation service by physician/qualified healthcare professional, each additional hour
PSYCL/NRPSYCL TST PHYS/QHP 2 + TST EA ADDL 30 MIN	Quoted text from source: PSYCL/NRPSYCL TST PHYS/QHP 2 + TST EA ADDL 30 MIN

Actions, requirements, and observed payer behavior

Denial Risk

Prior Authorization Determinations — Q2 2023

Prior authorization determinations (Q2 2023) were recorded by procedure/department and clinical indication. Most hospital admission requests were Approved; denials occurred across specialties and indications and were commonly coded as Not Medically Necessary, Non Covered Benefit, Failure to Notify, or Benefits Exhausted. Home Equipment & Home Services and other service areas also show a mix of Approvals and Denials in the quarter's reporting.

Q2 2023 reporting shows determinations listed by procedure and clinical indication with outcomes Approved or Denied (examples include Hospital Admission, Home Equipment & Home Services, Lab, Mental Health, Internal Medicine).
Observed denial reasons in Q2 2023: Not Medically Necessary; Non Covered Benefit; Failure to Notify; Benefits Exhausted.
Denials were triggered for hospital admission requests when the clinical indication was adjudicated as Not Medically Necessary or as a Non Covered Benefit (examples include Alcohol/Drug Use and Disorders, Respiratory System, Mental Illness in some records).
Home Equipment & Home Services had both approvals and denials in Q2 2023; denials there were recorded as Not Medically Necessary or Non Covered Benefit in the quarter's data.
Some denials reflect administrative issues (e.g., Failure to Notify) or benefit limits (Benefits Exhausted) rather than solely clinical appropriateness.
No step therapy requirements or step-therapy rules are described in the provided Q2 2023 prior authorization records.

Medical necessity criteria

Medical necessity criteria not specified

No explicit medical necessity criteria are provided in the source document; determinations (Approved or Denied) are logged by service and indication with denial reasons such as 'Not Medically Necessary' or other administrative codes.

Reported outcomes only: The document lists approvals and denials by procedure and clinical indication but does not provide the clinical criteria, objective thresholds, or specific supporting documentation required to establish medical necessity for Durable Medical Equipment or other services.

No diagnostic or functional criteria are specified in the source

Denial reasons referenced without criteria: Denials are recorded with reasons such as 'Not Medically Necessary', 'Non Covered Benefit', and 'Benefits Exhausted' but the policy language that defines when those reasons apply is not included in the provided text.

Operational adjudication rules not present

Home Equipment & Home Services — rental and purchase notes

Equipment / Service	Rental vs Purchase Rule	Notes
Home Equipment & Home Services	Not specified in the provided text	Quarterly prior authorization entries list determinations (Approved with Reason for Denial = N/A) but do not include any rental-versus-purchase rules

Replacement rules (if any)

Home Equipment & Home Services — replacement note

Equipment scopeHome Equipment & Home Services

Replacement interval specifiedNot specified in document

Documentation providedNo replacement rules or intervals are listed in the provided text

Documentation and submission guidance

Note

Key term definitions

Determination (outcome)

DefinitionDetermination = outcome assigned to a request (Approved or Denied)

Examples - ApprovedCardiac Surgery, Diagnostic Radiology, Hospital Admission, Lab entries show Approved determinations

Examples - DeniedDiagnostic Radiology, Home Equipment & Home Services, Hospital Admission, Lab entries show Denied determinations

Reason for Denial

DefinitionReason for Denial = payer-stated rationale recorded with a Denied determination (e.g., Not Medically Necessary, Non Covered Benefit)

Observed reason: Not Medically NecessaryHome Equipment & Home Services and multiple Hospital Admission and Lab entries list 'Not Medically Necessary'

Background and scope

This document is a listing of procedure categories, grouped clinical indications, and payer determinations (Approved or Denied) for the reporting period. Each entry pairs a procedure and clinical indication with the payer's determination and, when applicable, the recorded reason for denial (for example, "Not Medically Necessary" or "Non Covered Benefit"), organized as Second Quarter 2023 prior authorization statistics.

Non-covered items and notes

Items or requests within Home Equipment & Home Services that are listed as "Non Covered Benefit" in the report are treated as not covered by the payer for those specific cases. The dataset does not consistently identify the exact equipment item in every non‑covered entry, but records the non‑covered status for the affected requests.

OpenPayer

Prior authorization determinations for Home Equipment & Home Services (DME) — Quarterly report (Second Quarter 2023)