Guidelines Used for Prior Authorization

 

When a requested service is not addressed by a Medicare National Coverage Determination (NCD) or Local Coverage Determination (LCD), our plan may use InterQual® clinical criteria to help evaluate whether the service is medically necessary. InterQual is an evidence-based clinical decision support tool that incorporates current medical literature and accepted standards of care. Our clinical reviewers use these criteria, along with the member’s specific medical circumstances, to ensure prior authorization decisions are made consistently and appropriately. You may utilize the link below to view the InterQual® clinical criteria used.