As you are likely aware, Point32Health utilizes InterQual criteria for clinical authorization review for a number of services for our Harvard Pilgrim commercial, Tufts Health Plan commercial, and Tufts Health Public Plans products.
Please note that for the Medical Necessity Guidelines listed below, we will be adopting 2023 InterQual SmartSheets to replace the previous versions currently in use:
- Bariatric Surgery
- Blepharoplasty, Upper/Lower Eyelid and Brown and/or Eyelid Ptosis Repair
- Behavioral Health:
- Neuropsychological and Developmental Testing
- Psychological testing, Minnesota Multiphasic Personality Inventory-Adolescent® (MMPI-A®)
- Psychological testing, Minnesota Multiphasic Personality Inventory-2®(MMPI-2®)
- Psychological testing, Millon® Adolescent Clinical Inventory (MACI®)
- Psychological testing, Personality Assessment Inventory™ (PAI®)
- Psychological testing, unspecified symptom validity test (SVT)
- Psychological testing, unspecified test
- Requested Service: Repetitive Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation (TMS)
- Requested Service: Repetitive Transcranial Magnetic Stimulation tape
- Bronchial Thermoplasty (HPHC Commercial only)
- Cholecystectomy
- Custom Fabricated Oral Appliances
- Endoscopic Sinus Surgeries
- Genetic and Molecular Diagnostic Testing (THP Commercial only)
- Home Health Care
- Hysterectomy
- Implantable Neurostimulators
- Inpatient Acute Level of Care (Medical/Surgical)
- Manual Wheelchairs
- Mobile Cardiac Outpatient Telemetry
- Orthognathic Surgery for Severe Oral-Maxillofacial Function Disorders
- Osteogenesis Stimulators
- Outpatient PT/OT/ST (THP Public Plans only)
- Positive Airway Pressure Devices for Sleep Apnea
- Positive Airway Pressure Devices for Tufts Health RITogether and Tufts Health Unify
- Procedures for the Treatment of Symptomatic Varicose Veins
- Reconstructive and Cosmetic Services
- Surgical Procedures for the Treatment of Obstructive Sleep Apnea
- Temporomandibular Joint Disorder Treatment
- Vertebroplasty and Kyphoplasty
- Video Capsule Endoscopy
For complete information, refer to the associated Medical Necessity Guidelines.
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