Medical policies transitioning to 2020 InterQual® Criteria 

On September 14, some of our medical policies will start using InterQual® Criteria instead of custom criteria developed by Priority Health. This means our medical policies will align with nationally recognized decision support criteria. 

What is InterQual Criteria?

InterQual Criteria are evidence-based clinical decision support criteria developed by Change Healthcare and used across the health care industry. They let providers use a standardized approach to assess each patient’s unique situation and recommend the most appropriate care. 

Impacted policies:

91410 - Cardioverter Defibrillators

InterQual Criteria subset Procedure impacted
Implantable Cardioverter Defibrillator (ICD) insertion
  • Implantable Cardioverter Defibrillator (ICD) Insertion
  • Subcutaneous Implantable Cardioverter Defibrillator (SICD) Insertion
Pacemaker insertion Initial insertion of a permanent pacemaker
Pacemaker insertion, biventricular Biventricular pacemaker insertion only
Pacemaker insertion, biventricular + Implantable Cardioverter Defibrillator (ICD) insertion Criteria must be met for both the pacemaker and the ICD

91535 - Cosmetic and Reconstructive Surgery Procedures

InterQual Criteria subset Procedure impacted
Blepharoplasty Blepharoplasty
Ectropion repair Ectropion repair
Entropion repair Entropion repair
 Ptosis repair
  • Blepharoptosis repair
  • Brow Ptosis repair

91414 - Infusion Services and Equipment

InterQual Criteria subset Procedure impacted
Epidural or intrathecal catheter placement

Intrathecal drug delivery system insertion

91420 - Orthotics Shoe Inserts Ortho Shoes

InterQual Criteria subset Procedure impacted
Therapeutic shoes and inserts for persons with diabetes Therapeutic shoes and inserts for persons with diabetes

91444 - Panniculectomy/Abdominoplasty

InterQual Criteria subset Procedure impacted
Panniculectomy, abdominal Panniculectomy, abdominal

91127 - Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

InterQual Criteria subset Procedure impacted
Proton beam radiotherapy (PBRT); Proton beam radiotherapy (PBRT) pediatric
  • Charged particle radiation therapy
  • Charged particle radiotherapy
  • Proton beam radiation therapy
  • Proton radiation therapy
Stereotactic radiosurgery (SRS), brain or skull base
(This subset refers to gamma ray, x-ray, or photon modalities of stereotactic radiosurgery)
  • CyberKnife
  • Fractionated Stereotactic Radiotherapy
  • Gamma Knife
  • Linear Accelerator (LINAC)

91468 - Stimulation Therapy and Devices

InterQual Criteria subset Procedure impacted
Bone graft and implantable stimulator, fracture nonunion (applies to nonunion of fractures of the long bones) These criteria apply to nonunion of fractures of the long bones (e.g., humerus, radius, ulna, femur, tibia, fibula).
Stereotactic introduction, subcortical or cortical electrodes
  • Deep brain stimulation (DBS)
  • Intracranial electrode placement (Stereo-Electroencephalography (SEEG))
  • Radiofrequency (RF) lesioning
  • Responsive cortical stimulation
Vagus nerve stimulation; vagus nerve stimulation pediatric
  • Major depressive disorder
  • Refractory epilepsy

91544 - Hearing Augmentation

InterQual Criteria subset Procedure impacted
Cochlear implantation; Cochlear implantation pediatric
  • Unilateral cochlear implantation
  • Unilateral hybrid cochlear implantation
  • Simultaneous bilateral cochlear implantation
  • Sequential bilateral cochlear implantation
Hearing aid, bone anchored or one conduction
  • Unilateral percutaneous bone anchored hearing aid
  • Bilateral percutaneous bone anchored hearing aid
  • Unilateral transcutaneous bone conduction hearing aid
  • Bilateral transcutaneous bone conduction hearing aid