CUSTOMIZATIONS TO MCKESSON INTERQUAL CRITERIA Issue Date: December 19, 2013 Original Date: May 1, 2013

Transcription

1 CUSTOMIZATIONS TO MCKESSON INTERQUAL CRITERIA Issue Date: December 19, 2013 Original Date: May 1, 2013 NOTES: This document provides a high-level summary of customizations and modifications made to McKesson InterQual Criteria (from now on referred to as Customized Criteria). Customized Criteria are available on request. Benefit plans vary in coverage, and some plans may not provide coverage for certain services discussed in the Customized Criteria. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and applicable state and/or federal law. The Customized Criteria do not constitute plan authorization or a guarantee of payment, nor are they an explanation of benefits. We reserve the right to review and modify the InterQual Criteria or Customized Criteria at any time. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. The 2013 Edition of the InterQual Criteria and corresponding Customized Criteria will take effect May 1, The March 21, 2013, Amerigroup Medical Policy Committee review date reflects review and approval of (a) the licensed 2013 InterQual Criteria and (b) customizations to the 2013 Edition. The May 13, 2013 Amerigroup Medical Operations Committee (formerly Medical Policy Committee) review date reflects review and approval of (a) the licensed 2013 InterQual Criteria and (b) customizations to the 2013 Edition. The September 4, 2013 Amerigroup Medical Operations Committee review date reflects review and approval of the following changes to existing customizations to the Edition: o Care Planning (CP) Procedures Video Electroencephalographic (EEG) Monitoring Video Electroencephalographic (EEG) Monitoring (Pediatric) Issue Date: December 19, 2013 Page 1 of 30 not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.

2 Antireflux Procedures, Endoscopic Endoscopy, Upper Gastrointestinal (EGD) Endoscopy, Upper Gastrointestinal (EGD) (Pediatric) The December 12, 2013 Amerigroup Medical Operations Committee review date reflects review and approval of the following updates to the Edition: o Removed Customization Care Planning (CP) Procedures Ptosis Repair o New Care Planning (CP) Durable Medical Equipment Prosthetics, Lower Extremity Prosthetics, Lower Extremity - Senior o Retired Care Planning (CP) Durable Medical Equipment Prosthetics, Above Knee and Below Knee Prosthetics, Above Knee and Below Knee - Senior Prosthetics, Microprocessor-controlled, Knee INDEX (CTRL + Click to follow link) CUSTOMIZATIONS - BACKGROUND INFORMATION CUSTOMIZATIONS CARE PLANNING (CP) PROCEDURES Angioplasty and Stent, Carotid Antireflux Procedures, Endoscopic Antireflux Surgery or Hiatal Hernia Repair Aortic Valve Replacement (AVR) Arthroscopy, Surgical, Ankle Arthrotomy, Hip Arthrotomy, Knee Artificial Disc Replacement, Cervical Artificial Disc Replacement, Lumbar Atrial Septal Defect (ASD) Repair Bariatric Surgery Bone Augmentation, Mandible Bone Augmentation, Maxilla Bone Graft and Implantable Stimulator, Fracture Nonunion Brachytherapy, Prostate Breast Implant Removal Breast Reconstruction Capsule Endoscopy Cataract Removal Cochlear Implantation Cochlear Implantation (Pediatric) Issue Date: December 19, 2013 Page 2 of 30

3 Discectomy, Lumbar Electrocardiography, Ambulatory Electrophysiology (EP) Testing Endoscopy, Upper Gastrointestinal (EGD) Endoscopy, Upper Gastrointestinal (EGD) (Pediatric) Endovascular Repair, Aortic Aneurysm Endovenous Ablation, Varicose Veins Epidural Catheter Placement Ethmoidectomy Facet Joint Injection Facial Nerve Repair Fusion, Cervical Spine Fusion, Lumbar Spine Fusion, Thoracic Spine Gastric Stimulation Implantable Cardioverter Defibrillator (ICD) Insertion Interspinous Process Decompression Keratoplasty Laminectomy, Lumbar, +/- Fusion Left Ventricular Assist Device (LVAD) Insertion Liposuction Lung Volume Reduction Surgery (LVRS) Manipulation Under Anesthesia, Shoulder Maxillary Buttress Osteotomies, +/- Mid Palatal Osteotomy Maxillectomy Neuroablation, Percutaneous Osteotomy, Anterior Segment, Mandible Osteotomy, Anterior Segment, Maxilla Osteotomy, LeFort I Osteotomy, Mandible Ramus Osteotomy, Posterior Segment, Maxilla Pacemaker Insertion, Biventricular +/- ICD Insertion Panniculectomy, Abdominal Pectus Excavatum Repair (Pediatric) Percutaneous Coronary Interventions (PCI) Photocoagulation, Focal Laser Photocoagulation, Grid Laser Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT) Polypectomy, Nasal Polysomnogram (PSG) Polysomnogram (PSG) (Pediatric) Issue Date: December 19, 2013 Page 3 of 30

4 Prostatectomy, Transurethral Ablation Prostatectomy, Transurethral Resection Proton Beam Radiotherapy (PBRT) Ptosis Repair Radiofrequency Ablation (RFA) or Chemoembolization, Liver Radiofrequency Ablation (RFA), Cardiac Radiofrequency Ablation (RFA), Renal Reconstruction, Temporomandibular Joint (TMJ) Reduction Mammoplasty, Female Reduction Mammoplasty, Male Rhinoplasty Sclerotherapy, Varicose Veins Scoliosis Surgery Septoplasty Skin Graft Spinal Cord Stimulator (SCS) Insertion Stereotactic Introduction, Subcortical Electrodes Stereotactic Radiosurgery, Brain or Skull Base Sympathectomy Sympathetic Blockade Thoracic or Thoracoabdominal Aortic Aneurysm Repair Total Joint Replacement (TJR), Ankle Total Joint Replacement (TJR), Knee Transplantation, Allogeneic Stem Cell Transplantation, Autologous Stem Cell Transplantation, Cardiac Transplantation, Liver Transplantation, Renal Turbinectomy, Inferior, Partial Uvulopalatopharyngoplasty (UPPP) Vagal Nerve Stimulator Vertebroplasty or Kyphoplasty Video Electroencephalographic (EEG) Monitoring Video Electroencephalographic (EEG) Monitoring (Pediatric) CUSTOMIZATIONS CARE PLANNING (CP) DURABLE MEDICAL EQUIPMENT Bone Growth Stimulators, Noninvasive Bone Growth Stimulators, Noninvasive - Senior Cardioverter Defibrillator, Wearable (WCD) Cardioverter Defibrillator, Wearable (WCD) - Senior Negative Pressure Wound Therapy (NPWT) Pump Negative Pressure Wound Therapy (NPWT) Pump - Senior Issue Date: December 19, 2013 Page 4 of 30

5 Orthoses, Cranial Remodeling Orthoses, Spinal Orthoses, Spinal - Senior Prosthetics, Above Knee and Below Knee Prosthetics, Above Knee and Below Knee - Senior Prosthetics, Lower Extremity Prosthetics, Lower Extremity - Senior Prosthetics, Microprocessor-controlled, Knee Secretion Clearance Devices Secretion Clearance Devices - Senior Standing Frames CUSTOMIZATIONS LEVEL OF CARE: OUTPATIENT REHABILITATION & CHIROPRACTIC Traumatic Brain Injury (TBI): Rehabilitation (Adult) CUSTOMIZATION HISTORY Return to Index CUSTOMIZATIONS BACKGROUND INFORMATION Types of : 1. to InterQual criteria are based on integration with our medical policy. 2. Customization to InterQual criteria may include replacing the criteria with a note to use a medical policy or clinical utilization management guideline. 3. to InterQual criteria may include adding an Organizational Policy Note to see a related medical policy. Review and Approval of : The Amerigroup Medical Operations Committee (MOC) (formerly Medical Policy Committee [MPC]) reviews and approves all customizations to InterQual criteria. In addition, when a new edition of InterQual criteria is released, the new edition is reviewed and approved by the MPC. Disclaimer: The list of customized guidelines includes a disclaimer indicating: InterQual copyright 2013 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications, and their inclusion herein does not imply endorsement by McKesson of modifications. Return to Index Issue Date: December 19, 2013 Page 5 of 30

6 CUSTOMIZATIONS CARE PLANNING (CP) PROCEDURES (ADULT AND PEDIATRIC) Angioplasty and Stent, Carotid o Removed criteria and replaced with the following: Angioplasty and Stent, Carotid (May 1, 2013) For carotid angioplasty and stent, see SURG Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement. Antireflux Procedures, Endoscopic Added Organizational Policy: Organizational Policy (Antireflux Procedures, Endoscopic May 1, 2013) NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see SURG Transendoscopic Therapy for Gastroesophageal Reflux Disease. NOTE: For in vivo analysis of gastrointestinal lesions, see MED In-Vivo Analysis of Gastrointestinal Lesions. September 4, 2013 AGP MOC review: Revision: Medical Policy retitled. Added "and Dysphagia" Organizational Policy (Antireflux Procedures, Endoscopic August 08, 2013) NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see SURG Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia. NOTE: For in vivo analysis of gastrointestinal lesions, see MED In-Vivo Analysis of Gastrointestinal Lesions. Antireflux Surgery or Hiatal Hernia Repair Aortic Valve Replacement (AVR) Added Organizational Policy: Organizational Policy (Antireflux Surgery or Hiatal Hernia Repair May 1, 2013) NOTE: For lower esophageal sphincter augmentation devices for the treatment of gastroesophageal reflux disease (GERD), see SURG Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD). Added Organizational Policy: Organizational Policy (Aortic Valve Replacement [AVR] May 1, 2013) Issue Date: December 19, 2013 Page 6 of 30

7 NOTE: When the procedure uses the transcatheter approach (as opposed to open), see SURG Transcatheter Heart Valves. Arthroscopy, Surgical, Ankle May 13, 2013 MOC review: Added Organizational Policy: Organizational Policy (Arthroscopy, Surgical, Ankle May 13, 2013) NOTE: For treatment of osteochondral defects, see SURG Treatment of Osteochondral Defects. Arthrotomy, Hip Added Organizational Policy: Organizational Policy (Arthrotomy, Hip May 1, 2013) NOTE: For hip resurfacing, see SURG Hip Resurfacing. NOTE: For surgical treatment of femoroacetabular impingement syndrome (FAIS), see SURG Surgical Treatment of Femoroacetabular Impingement Syndrome. NOTE: For sacroiliac joint fusion, see SURG Sacroiliac Joint Fusion. Arthrotomy, Knee Added Organizational Policy: Organizational Policy (Arthrotomy, Knee May 1, 2013) NOTE: For bicompartmental knee arthroplasty, see SURG Bicompartmental Knee Arthroplasty. Artificial Disc Replacement, Cervical Artificial Disc Replacement, Lumbar Removed criteria and replaced with the following: Artificial Disc Replacement, Cervical (May 1, 2013) For cervical artificial disc replacement, see SURG Cervical Artificial Intervertebral Discs. May 13, 2013 AGP MOC review: Removed criteria and replaced with the following: Artificial Disc Replacement, Lumbar (May 13, 2013) For lumbar artificial disc replacement, see CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID). Issue Date: December 19, 2013 Page 7 of 30

8 Atrial Septal Defect (ASD) Repair Bariatric Surgery Added Organizational Policy: Organizational Policy (Atrial Septal Defect (ASD) Repair May 1, 2013) NOTE: For transcatheter closure of patent foramen ovale and left atrial appendage for stroke prevention, see SURG Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention. Removed criteria and replaced with the following: Bariatric Surgery (May 1, 2013) For bariatric surgery, see SURG Surgery for Clinically Severe Obesity. Bone Augmentation, Mandible Removed criteria and replaced with the following: Bone Augmentation, Mandible (May 1, 2013) For bone augmentation, mandible, see SURG Mandibular/Maxillary (Orthognathic) Surgery. NOTE: For facial plastic surgery, see ANC Cosmetic and Reconstructive Services of the Head and Neck. Bone Augmentation, Maxilla Removed criteria and replaced with the following: Bone Augmentation, Maxilla (May 1, 2013) For bone augmentation, maxilla, see SURG Mandibular/Maxillary (Orthognathic) Surgery. NOTE: For facial plastic surgery, see ANC Cosmetic and Reconstructive Services of the Head and Neck. Bone Graft and Implantable Stimulator, Fracture Nonunion Removed criteria and replaced with the following: Bone Graft and Implantable Stimulator, Fracture Nonunion (May 1, 2013) For bone graft and implantable stimulator, fracture nonunion, see DME Electrical Bone Growth Stimulation. Issue Date: December 19, 2013 Page 8 of 30

9 Brachytherapy, Prostate Removed criteria and replaced with the following: Brachytherapy, Prostate (May 1, 2013) For prostate brachytherapy, see RAD Brachytherapy for Oncologic Indications. Breast Implant Removal Removed criteria and replaced with the following: Breast Implant Removal (May 1, 2013) For breast implant removal, see SURG Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures. Breast Reconstruction Removed criteria and replaced with the following: Breast Reconstruction (May 1, 2013) For breast reconstruction, see SURG Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures. Capsule Endoscopy Removed criteria and replaced with the following: Capsule Endoscopy (May 1, 2013) For capsule endoscopy, see RAD Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule. Cataract Removal Added Organizational Policy: Organizational Policy ( Cataract Removal May 1, 2013) NOTE: When the procedure is clear lens extraction with or without implantation of an accommodating or nonaccommodating lens, see SURG Refractive Surgery. Cochlear Implantation Removed criteria and replaced with the following: Cochlear Implantation (May 1, 2013) Issue Date: December 19, 2013 Page 9 of 30

10 For cochlear implantation, see SURG Cochlear Implants and Auditory Brainstem Implants. Cochlear Implantation (Pediatric) Discectomy, Lumbar Removed criteria and replaced with the following: Cochlear Implantation (Pediatric) (May 1, 2013) For cochlear implantation (pediatric), see SURG Cochlear Implants and Auditory Brainstem Implants. Added Organizational Policy: Organizational Policy (Discectomy, Lumbar May 1, 2013) NOTE: When the procedure uses the percutaneous or endoscopic approach (as opposed to open with direct visualization), see SURG Percutaneous and Endoscopic Spinal Surgery. Electrocardiography, Ambulatory May 13, 2013 MOC review: Removed criteria and replaced with the following: Electrocardiography, Ambulatory (May 13, 2013) For ambulatory event monitors, see CG-MED-40 Ambulatory Event Monitors to Detect Cardiac Arrhythmias. For Holter monitors, see CG-MED-44 Holter Monitors. NOTE: For real-time remote heart monitors, see MED Real-Time Remote Heart Monitors. Added Organizational Policy: Organizational Policy (Electrocardiography, Ambulatory May 1, 2013) NOTE: For real-time remote heart monitors, see MED Real-Time Remote Heart Monitors. Electrophysiology (EP) Testing Added Organizational Policy: Issue Date: December 19, 2013 Page 10 of 30

11 Organizational Policy (Electrophysiology [EP] Testing May 1, 2013) NOTE: When the procedure is transcatheter ablation of arrhythmogenic foci in the pulmonary veins, see MED Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation). Endoscopy, Upper Gastrointestinal (EGD) Added Organizational Policy: Organizational Policy (Endoscopy, Upper Gastrointestinal [EGD] May 1, 2013) NOTE: For ablative techniques as a treatment for Barrett's esophagus, see SURG Ablative Techniques as a Treatment for Barrett's Esophagus. NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see SURG Transendoscopic Therapy for Gastroesophageal Reflux Disease. NOTE: For in vivo analysis of gastrointestinal lesions, see MED In-Vivo Analysis of Gastrointestinal Lesions. September 4, 2013 AGP MOC review: Revision: Medical Policy retitled. Added "and Dysphagia" Organizational Policy (Endoscopy, Upper Gastrointestinal [EGD] August 08, 2013) NOTE: For ablative techniques as a treatment for Barrett's esophagus, see SURG Ablative Techniques as a Treatment for Barrett's Esophagus. NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see SURG Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia. NOTE: For in vivo analysis of gastrointestinal lesions, see MED In-Vivo Analysis of Gastrointestinal Lesions. Endoscopy, Upper Gastrointestinal (EGD) (Pediatric) Added Organizational Policy: Organizational Policy (Endoscopy, Upper Gastrointestinal [EGD] [Pediatric] May 1, 2013) NOTE: For ablative techniques as a treatment for Barrett's esophagus, see SURG Ablative Techniques as a Treatment for Barrett's Esophagus. NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see SURG Transendoscopic Therapy for Gastroesophageal Reflux Disease. September 4, 2013 AGP MOC review: Revision: Medical Policy retitled. Added "and Dysphagia" Issue Date: December 19, 2013 Page 11 of 30

12 Organizational Policy (Endoscopy, Upper Gastrointestinal [EGD] [Pediatric] August 08, 2013) NOTE: For ablative techniques as a treatment for Barrett's esophagus, see SURG Ablative Techniques as a Treatment for Barrett's Esophagus. NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see SURG Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia. Endovascular Repair, Aortic Aneurysm Endovenous Ablation, Varicose Veins Epidural Catheter Placement Removed criteria and replaced with the following: Endovascular Repair, Aortic Aneurysm (May 1, 2013) For endovascular repair of abdominal aortic aneurysm, see SURG Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection. Removed criteria and replaced with the following: Endovenous Ablation, Varicose Veins (May 1, 2013) For endovenous ablation, varicose veins, see SURG Treatment of Varicose Veins (Lower Extremities). Added Organizational Policy: Organizational Policy (Epidural Catheter Placement May 1, 2013) NOTE: For implantable infusion pumps, see SURG Implantable Infusion Pumps. Ethmoidectomy Added Organizational Policy: Organizational Policy (Ethmoidectomy May 1, 2013) NOTE: When the procedure is for the treatment of chronic headaches, see SURG Surgical and Ablative Treatments for Chronic Headaches. Facet Joint Injection May 13, 2013 AGP MOC review: Removed criteria and replaced with the following: Facet Joint Injection (May 13, 2013) For facet joint injection, see CG-SURG-32 Pain Management: Cervical, Thoracic & Lumbar Issue Date: December 19, 2013 Page 12 of 30

13 Facet Injection. Facial Nerve Repair Added Organizational Policy: Organizational Policy (Facial Nerve Repair May 1, 2013) NOTE: For facial plastic surgery, see ANC Cosmetic and Reconstructive Services of the Head and Neck. Fusion, Cervical Spine Added Organizational Policy: Organizational Policy (Fusion, Cervical Spine May 1, 2013) NOTE: For facet joint allograft implant(s), see SURG Facet Joint Allograft Implants for Facet Disease. Fusion, Lumbar Spine May 13, 2013 AGP MOC review: Removed criteria and replaced with the following: Fusion, Lumbar Spine (May 13, 2013) For lumbar spine fusion, see CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID). Fusion, Thoracic Spine Added Organizational Policy: Organizational Policy (Fusion, Thoracic Spine May 1, 2013) NOTE: For facet joint allograft implant(s), see SURG Facet Joint Allograft Implants for Facet Disease. Gastric Stimulation Removed criteria and replaced with the following: Gastric Stimulation (May 1, 2013) For gastric stimulation, see SURG Gastric Electrical Stimulation. Implantable Cardioverter Defibrillator (ICD) Insertion Removed criteria and replaced with the following: Implantable Cardioverter Defibrillator (ICD) Insertion (May 1, 2013) Issue Date: December 19, 2013 Page 13 of 30

14 For implantable cardioverter defibrillator (ICD) insertion, see the following: SURG Implantable Cardioverter-Defibrillator (ICD) SURG Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Interspinous Process Decompression Keratoplasty Removed criteria and replaced with the following: Interspinous Process Decompression (May 1, 2013) For interspinous process decompression, see SURG Implanted Devices for Spinal Stenosis. Added Organizational Policy: Organizational Policy (Keratoplasty May 1, 2013) NOTE: For endothelial keratoplasty, see SURG Endothelial Keratoplasty. NOTE: For keratomileusis, see SURG Refractive Surgery. Laminectomy, Lumbar, +/- Fusion May 13, 2013 AGP MOC review: Added Organizational Policy: Organizational Policy (Laminectomy, Lumbar, +/- Fusion May 13, 2013) NOTE: For lumbar fusion, see CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID). Left Ventricular Assist Device (LVAD) Insertion Liposuction Removed criteria and replaced with the following: Left Ventricular Assist Device (LVAD) Insertion (May 1, 2013) For left ventricular assist device (LVAD) insertion, see TRANS Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts). Added Organizational Policy Organizational Policy (Liposuction May 1, 2013) NOTE: Several medical policies address liposuction; review medical policies first to determine if they address the service requested before using InterQual. Issue Date: December 19, 2013 Page 14 of 30

15 Lung Volume Reduction Surgery (LVRS) Manipulation Under Anesthesia, Shoulder Maxillary Buttress Osteotomies, +/- Mid Palatal Osteotomy Removed criteria and replaced with the following: Lung Volume Reduction Surgery (LVRS) (May 1, 2013) For lung volume reduction surgery (LVRS), see SURG Lung Volume Reduction Surgery. Removed criteria and replaced with the following: Manipulation Under Anesthesia, Shoulder (May 1, 2013) For manipulation under anesthesia, shoulder, see MED Manipulation Under Anesthesia of the Spine and Joints other than the Knee. Removed criteria and replaced with the following: Maxillary Buttress Osteotomies, +/- Mid Palatal Osteotomy (May 1, 2013) For maxillary buttress osteotomies, +/- mid palatal osteotomy, see SURG Mandibular/Maxillary (Orthognathic) Surgery. NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see SURG Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea. Maxillectomy Removed criteria and replaced with the following: Maxillectomy (May 1, 2013) For maxillectomy, see SURG Mandibular/Maxillary (Orthognathic) Surgery. Neuroablation, Percutaneous Added Organizational Policy: Organizational Policy (Neuroablation, Percutaneous May 1, 2013) NOTE: Several medical policies address percutaneous neuroablation; review medical policies first to determine if they address the service requested before using InterQual. Osteotomy, Anterior Segment, Mandible Removed criteria and replaced with the following: Issue Date: December 19, 2013 Page 15 of 30

16 Osteotomy, Anterior Segment, Mandible (May 1, 2013) For osteotomy, anterior segment, mandible, see SURG Mandibular/Maxillary (Orthognathic) Surgery. NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see SURG Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea. Osteotomy, Anterior Segment, Maxilla Removed criteria and replaced with the following: Osteotomy, Anterior Segment, Maxilla (May 1, 2013) For osteotomy, anterior segment, maxilla, see SURG Mandibular/Maxillary (Orthognathic) Surgery. NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see SURG Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea. Osteotomy, LeFort I Removed criteria and replaced with the following: Osteotomy, LeFort I (May 1, 2013) For osteotomy, LeFort I, see SURG Mandibular/Maxillary (Orthognathic) Surgery. Osteotomy, Mandible Ramus Removed criteria and replaced with the following: Osteotomy, Mandible Ramus (May 1, 2013) For osteotomy, mandible ramus, see SURG Mandibular/Maxillary (Orthognathic) Surgery. NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see SURG Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea. Osteotomy, Posterior Segment, Maxilla Removed criteria and replaced with the following: Osteotomy, Posterior Segment, Maxilla (May 1, 2013) For osteotomy, posterior segment, maxilla, see SURG Mandibular/Maxillary Issue Date: December 19, 2013 Page 16 of 30

17 (Orthognathic) Surgery. NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see SURG Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea. Pacemaker Insertion, Biventricular +/- ICD Insertion Panniculectomy, Abdominal Removed criteria and replaced with the following: Pacemaker Insertion, Biventricular +/- ICD Insertion (May 1, 2013) For Pacemaker Insertion, Biventricular +/- ICD insertion, see the following: SURG Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure SURG Implantable Cardioverter-Defibrillator (ICD) Removed criteria and replaced with the following: Panniculectomy, Abdominal (May 1, 2013) For abdominal panniculectomy, see SURG Panniculectomy and Abdominoplasty. Pectus Excavatum Repair (Pediatric) Removed criteria and replaced with the following: Pectus Excavatum Repair (Pediatric) (May 1, 2013) For pectus excavatum repair, see ANC Cosmetic and Reconstructive Services of the Trunk and Groin. Percutaneous Coronary Interventions (PCI) Photocoagulation, Focal Laser Added Organizational Policy: Organizational Policy (Percutaneous Coronary Interventions (PCI) May 1, 2013) NOTE: For coronary intravascular brachytherapy, see RAD Intravascular Brachytherapy (Coronary and Non-Coronary). Added Organizational Policy: Organizational Policy (Photocoagulation, Focal Laser May 1, 2013) NOTE: For photocoagulation of macular drusen, see SURG Photocoagulation of Issue Date: December 19, 2013 Page 17 of 30

18 Macular Drusen. Photocoagulation, Grid Laser Added Organizational Policy: Organizational Policy (Photocoagulation, Grid Laser May 1, 2013) NOTE: For photocoagulation of macular drusen, see SURG Photocoagulation of Macular Drusen. Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT) Polypectomy, Nasal Removed criteria and replaced with the following: Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT) (May 1, 2013) For extracorporeal shock wave therapy (ESWT) for plantar fasciitis, see SURG Extracorporeal Shock Wave Therapy for Orthopedic Conditions. Added Organizational Policy: Organizational Policy (Polypectomy, Nasal May 1, 2013) NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see SURG Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring. Polysomnogram (PSG) May 13, 2013 MOC review: Added Organizational Policy: Organizational Policy (Polysomnogram [PSG] May 13, 2013) NOTE: For actigraphy testing, see MED Selected Sleep Testing Services. Polysomnogram (PSG) (Pediatric) May 13, 2013 MOC review: Added Organizational Policy: Organizational Policy (Polysomnogram [PSG] [Pediatric] May 13, 2013) NOTE: For actigraphy testing, see MED Selected Sleep Testing Services. Prostatectomy, Transurethral Ablation Removed criteria and replaced with the following: Prostatectomy, Transurethral Ablation (May 1, 2013) Issue Date: December 19, 2013 Page 18 of 30

19 For transurethral ablation of the prostate, see SURG Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions. Prostatectomy, Transurethral Resection Proton Beam Radiotherapy (PBRT) Ptosis Repair Added Organizational Policy: Organizational Policy (Prostatectomy, Transurethral Resection May 1, 2013) NOTE: For laser-based procedures, transurethral incision of the prostate, and transurethral vapor resection of the prostate, see SURG Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions. Removed criteria and replaced with the following: Proton Beam Radiotherapy (PBRT) (May 1, 2013) For proton beam radiotherapy (PBRT), see RAD Proton Beam Radiation Therapy. December 12, 2013 AGP MPC review: Removed customization based on McKesson removing coding related to SURG Surgical and Ablative Treatments for Chronic Headaches. Added Organizational Policy: Organizational Policy (Ptosis Repair May 1, 2013) NOTE: When the procedure is for the treatment of chronic headaches, see SURG Surgical and Ablative Treatments for Chronic Headaches. Radiofrequency Ablation (RFA) or Chemoembolization, Liver Removed criteria and replaced with the following: Radiofrequency Ablation (RFA) or Chemoembolization, Liver (May 1, 2013) For radiofrequency ablation (RFA) or chemoembolization, liver, see the following: RAD Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors SURG Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies NOTE: For related procedures, see the following: RAD Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Issue Date: December 19, 2013 Page 19 of 30

20 Tumors (i.e., SIR-Sphere and TheraSpheres) SURG Irreversible Electroporation (IRE) Radiofrequency Ablation (RFA), Cardiac Radiofrequency Ablation (RFA), Renal Reconstruction, Temporomandibular Joint (TMJ) Reduction Mammoplasty, Female Added Organizational Policy: Organizational Policy (Radiofrequency Ablation [RFA], Cardiac May 1, 2013) NOTE: When the procedure is transcatheter ablation of arrhythmogenic foci in the pulmonary veins, see MED Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation). Removed criteria and replaced with the following: Radiofrequency Ablation (RFA), Renal (May 1, 2013) For radiofrequency ablation (RFA), renal, see SURG Radiofrequency Ablation to Treat Tumors Outside the Liver. Added Organizational Policy: Organizational Policy (Reconstruction, Temporomandibular Joint [TMJ] May 1, 2013) NOTE: For facial plastic surgery, see ANC Cosmetic and Reconstructive Services of the Head and Neck. Removed criteria and replaced with the following: Reduction Mammoplasty, Female (May 1, 2013) For reduction mammoplasty, female, see SURG Reduction Mammaplasty. NOTE: For related procedures, see the following: SURG Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures Reduction Mammoplasty, Male Removed criteria and replaced with the following: Reduction Mammoplasty, Male (May 1, 2013) For reduction mammoplasty, male, see SURG Mastectomy for Gynecomastia. Issue Date: December 19, 2013 Page 20 of 30

21 NOTE: For related procedures, see the following: SURG Reduction Mammaplasty SURG Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures Rhinoplasty Removed criteria and replaced with the following: Rhinoplasty (May 1, 2013) For rhinoplasty, see ANC Cosmetic and Reconstructive Services of the Head and Neck. Sclerotherapy, Varicose Veins Removed criteria and replaced with the following: Sclerotherapy, Varicose Veins (May 1, 2013) For sclerotherapy, varicose veins, see SURG Treatment of Varicose Veins (Lower Extremities). Scoliosis Surgery May 13, 2013 MOC review: Added Organizational Policy: Organizational Policy (Scoliosis Surgery May 13, 2013) NOTE: For lumbar fusion for degenerative scoliosis, see CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID). Skin Graft May 13, 2013 MOC review: Added Organizational Policy: Organizational Policy (Skin Graft, May 13, 2013) NOTE: For allogeneic, xenographic, synthetic and composite products for wound healing and soft tissue grafting, see SURG Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting. Septoplasty Added Organizational Policy: Organizational Policy (Septoplasty May 1, 2013) NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see SURG Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring. Issue Date: December 19, 2013 Page 21 of 30

22 NOTE: When the procedure is for the treatment of chronic headaches, see SURG Surgical and Ablative Treatments for Chronic Headaches. Spinal Cord Stimulator (SCS) Insertion Stereotactic Introduction, Subcortical Electrodes Stereotactic Radiosurgery, Brain or Skull Base Removed criteria and replaced with the following: Spinal Cord Stimulator (SCS) Insertion (May 1, 2013) For spinal cord stimulator (SCS) insertion, see SURG Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS). Removed criteria and replaced with the following: Stereotactic Introduction, Subcortical Electrodes (May 1, 2013) For stereotactic introduction, subcortical electrodes, see SURG Deep Brain Stimulation. Removed criteria and replaced with the following: Stereotactic Radiosurgery, Brain or Skull Base (May 1, 2013) For stereotactic radiosurgery, brain or skull base, see SURG Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT). NOTE: For related information, see the following: RAD Proton Beam Radiation Therapy Sympathectomy Added Organizational Policy: Organizational Policy (Sympathectomy May 1, 2013) NOTE: For treatment of hyperhidrosis, see MED Treatment of Hyperhidrosis Sympathetic Blockade Added Organizational Policy: Organizational Policy (Sympathetic Blockade May 1, 2013) NOTE: For treatment of hyperhidrosis, see MED Treatment of Hyperhidrosis Issue Date: December 19, 2013 Page 22 of 30

23 Thoracic or Thoracoabdominal Aortic Aneurysm Repair Total Joint Replacement (TJR), Ankle Total Joint Replacement (TJR), Knee Transplantation, Allogeneic Stem Cell Transplantation, Autologous Stem Cell Transplantation, Cardiac Added Organizational Policy: Organizational Policy (Thoracic or Thoracoabdominal Aortic Aneurysm Repair May 1, 2013) NOTE: For endovascular/ endoluminal repair of thoracic/ thoracoabdominal aortic aneurysm, see SURG Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection. Removed criteria and replaced with the following: Total Joint Replacement (TJR), Ankle (May 1, 2013) For total joint replacement (TJR), ankle, see SURG Total Ankle Replacement. Added Organizational Policy: Organizational Policy (Total Joint Replacement [TJR], Knee May 1, 2013) NOTE: For bicompartmental knee arthroplasty, see SURG Bicompartmental Knee Arthroplasty. Removed criteria and replaced with the following: Transplantation, Allogeneic Stem Cell (May 1, 2013) For allogeneic stem cell transplantation, see the applicable medical policy. Removed criteria and replaced with the following: Transplantation, Autologous Stem Cell (May 1, 2013) For autologous stem cell transplantation, see the applicable medical policy. Removed criteria and replaced with the following: Transplantation, Cardiac (May 1, 2013) For cardiac transplantation, see TRANS Heart Transplantation. Issue Date: December 19, 2013 Page 23 of 30

24 Transplantation, Liver Removed criteria and replaced with the following: Transplantation, Liver (May 1, 2013) For liver transplantation, see TRANS Liver Transplantation. Transplantation, Renal Added Organizational Policy: Organizational Policy (Transplantation, Renal May 1, 2013) NOTE: For pancreas kidney transplantation, see TRANS Pancreas Transplantation and Pancreas Kidney Transplantation. Turbinectomy, Inferior, Partial Added Organizational Policy: Organizational Policy ( Turbinectomy, Inferior, Partial May 1, 2013) NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see SURG Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring. NOTE: When the procedure is for the treatment of chronic headaches, see SURG Surgical and Ablative Treatments for Chronic Headaches. Uvulopalatopharyngoplasty (UPPP) Removed criteria and replaced with the following: Uvulopalatopharyngoplasty (UPPP) (May 1, 2013) For uvulopalatopharyngoplasty (UPPP) and laser-assisted uvulopalatoplasty (LAUP), see SURG Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea. Vagal Nerve Stimulator Removed criteria and replaced with the following: Vagal Nerve Stimulator (May 1, 2013) For vagal nerve stimulator, see SURG Vagus Nerve Stimulation. Vertebroplasty or Kyphoplasty Removed criteria and replaced with the following: Issue Date: December 19, 2013 Page 24 of 30

25 Vertebroplasty or Kyphoplasty (May 1, 2013) For vertebroplasty or kyphoplasty, see SURG Percutaneous Spinal Procedures (Vertebroplasty, Kyphoplasty and Sacroplasty). Video Electroencephalographic (EEG) Monitoring May 13, 2013 MOC review: Added Organizational Policy: Organizational Policy (Video Electroencephalographic [EEG] May 13, 2013) NOTE: For ambulatory electroencephalographic (EEG) monitoring, see CG-MED-46 Ambulatory Electroencephalography. September 4, 2013 MOC review: Correct GL Title: Added "Monitoring" Organizational Policy (Video Electroencephalographic [EEG] Monitoring August 08, 2013) NOTE: For ambulatory electroencephalographic (EEG) monitoring, see CG-MED-46 Ambulatory Electroencephalography. Video Electroencephalographic (EEG) Monitoring (Pediatric) May 13, 2013 MOC review: Added Organizational Policy: Organizational Policy (Video Electroencephalographic [EEG] [Pediatric]) May 13, 2013) NOTE: For ambulatory electroencephalographic (EEG) monitoring, see CG-MED-46 Ambulatory Electroencephalography. September 4, 2013 MOC review: Correct GL Title: Added "Monitoring" Organizational Policy (Video Electroencephalographic [EEG] Monitoring [Pediatric] August 08, 2013) NOTE: For ambulatory electroencephalographic (EEG) monitoring, see CG-MED-46 Ambulatory Electroencephalography. Return to Index Issue Date: December 19, 2013 Page 25 of 30

26 CUSTOMIZATIONS CARE PLANNING (CP) DURABLE MEDICAL EQUIPMENT Bone Growth Stimulators, Noninvasive Bone Growth Stimulators, Noninvasive - Senior Cardioverter Defibrillator, Wearable (WCD) Cardioverter Defibrillator, Wearable (WCD) - Senior Negative Pressure Wound Therapy (NPWT) Pump Negative Pressure Removed criteria and replaced with the following: Bone Growth Stimulators, Noninvasive (May 1, 2013) For noninvasive bone growth stimulators, see the following: DME Ultrasound Bone Growth Stimulation DME Electrical Bone Growth Stimulation Removed criteria and replaced with the following: Bone Growth Stimulators, Noninvasive - Senior (May 1, 2013) For noninvasive bone growth stimulators, see the following: DME Ultrasound Bone Growth Stimulation DME Electrical Bone Growth Stimulation Removed criteria and replaced with the following: Cardioverter Defibrillator, Wearable (WCD) (May 1, 2013) For wearable cardioverter defibrillator, see MED Wearable Cardioverter Defibrillators. Removed criteria and replaced with the following: Cardioverter Defibrillator, Wearable (WCD) - Senior (May 1, 2013) For wearable cardioverter defibrillator, see MED Wearable Cardioverter Defibrillators. Removed criteria and replaced with the following: Negative Pressure Wound Therapy (NPWT) Pump (May 1, 2013) For negative pressure wound therapy (NPWT) pump, see DME Vacuum Assisted Wound Therapy in the Outpatient Setting. Issue Date: December 19, 2013 Page 26 of 30

27 Wound Therapy (NPWT) Pump - Senior Orthoses, Cranial Remodeling Removed criteria and replaced with the following: Negative Pressure Wound Therapy (NPWT) Pump - Senior (May 1, 2013) For negative pressure wound therapy (NPWT) pump, see DME Vacuum Assisted Wound Therapy in the Outpatient Setting. Removed criteria and replaced with the following: Orthoses, Cranial Remodeling (May 1, 2013) For cranial remodeling orthoses, see CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics). Orthoses, Spinal Added Organizational Policy: Organizational Policy (Orthoses, Spinal May 1, 2013) NOTE: For self-operated spinal unloading devices, see DME Self-Operated Spinal Unloading Devices. Orthoses, Spinal - Senior May 13, 2013 AGP MOC review: Added Organizational Policy: Organizational Policy (Orthoses, Spinal - Senior May 13, 2013) NOTE: For self-operated spinal unloading devices, see DME Self-Operated Spinal Unloading Devices. Prosthetics, Above Knee and Below Knee December 12, 2013 AGP MPC review: Guideline retired. McKesson replaced guideline with Prosthetics, Lower Extremity. Added Organizational Policy: Organizational Policy (Prosthetics, Above Knee and Below Knee May 1, 2013) NOTE: For microprocessor controlled lower limb prosthesis, see OR-PR Microprocessor Controlled Lower Limb Prosthesis. Prosthetics, Above Knee and Below Knee - Senior December 12, 2013 AGP MPC review: Guideline retired. McKesson replaced guideline with Prosthetics, Lower Extremity - Senior. Issue Date: December 19, 2013 Page 27 of 30

28 Added Organizational Policy: Organizational Policy (Prosthetics, Above Knee and Below Knee - Senior May 1, 2013) NOTE: For microprocessor-controlled lower limb prosthesis, see OR-PR Microprocessor Controlled Lower Limb Prosthesis. Prosthetics, Lower Extremity December 12, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Prosthetics, Lower Extremity December 19, 2013) NOTE: For microprocessor-controlled lower limb prosthesis, see OR-PR Microprocessor Controlled Lower Limb Prosthesis. Prosthetics, Lower Extremity - Senior December 12, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Prosthetics, Lower Extremity - Senior December 19, 2013) NOTE: For microprocessor-controlled lower limb prosthesis, see OR-PR Microprocessor Controlled Lower Limb Prosthesis. Prosthetics, Microprocessorcontrolled, Knee December 12, 2013 AGP MPC review: Guideline retired. McKesson replaced guideline with Prosthetics, Lower Extremity. Removed criteria and replaced with the following: Prosthetics, Microprocessor-controlled, Knee (May 1, 2013) For microprocessor-controlled lower limb prosthesis, see OR-PR Microprocessor Controlled Lower Limb Prosthesis. Secretion Clearance Devices Removed criteria and replaced with the following: Secretion Clearance Devices (May 1, 2013) For secretion clearance devices, see DME Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV). Issue Date: December 19, 2013 Page 28 of 30

29 Secretion Clearance Devices - Senior Standing Frames Removed criteria and replaced with the following: Secretion Clearance Devices - Senior (May 1, 2013) For secretion clearance devices, see DME Oscillatory Devices for Airway Clearance, including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV). Removed criteria and replaced with the following: Standing Frames (May 1, 2013) For standing frames, see DME Standing Frames. Return to Index CUSTOMIZATIONS LEVEL OF CARE (LOC): OUTPATIENT REHABILITATION & CHIROPRACTIC Traumatic Brain Injury (TBI): Rehabilitation (Adult) Added Organizational Policy: Organizational Policy (Traumatic Brain Injury (TBI): Rehabilitation [Adult] May 1, 2013) NOTE: For cognitive rehabilitation, see MED Cognitive Rehabilitation. Return to Index CUSTOMIZATION HISTORY Date Action Reason 12/19/2013 Release updated document for to McKesson InterQual Criteria Updated document for to McKesson InterQual Criteria The December 12, 2013 Amerigroup Medical Operations Committee reviewed and approved the following Issue Date: December 19, 2013 Page 29 of 30

30 Date Action Reason updates to the Edition: o Removed Customization Care Planning (CP) Procedures Ptosis Repair o New Care Planning (CP) Durable Medical Equipment Prosthetics, Lower Extremity Prosthetics, Lower Extremity Senior o Retired Care Planning (CP) Durable Medical Equipment Prosthetics, Above Knee and Below Knee Prosthetics, Above Knee and Below Knee - Senior Prosthetics, Microprocessor-controlled, Knee 09/27/2013 Release updated document for Updated document for to McKesson to McKesson InterQual Criteria InterQual Criteria The September 4, 2013 Amerigroup Medical Operations Committee reviewed and approved the following revised customizations to the Edition: o Care Planning (CP) Procedures Video Electroencephalographic (EEG) Monitoring Video Electroencephalographic (EEG) Monitoring (Pediatric) Antireflux Procedures, Endoscopic Endoscopy, Upper Gastrointestinal (EGD) Endoscopy, Upper Gastrointestinal (EGD) (Pediatric) 6/28/2013 Release updated document for to McKesson InterQual Criteria /01/2013 Release document for to McKesson InterQual Criteria Return to Index Updated document for to McKesson InterQual Criteria The May 13, 2013 Amerigroup Medical Operations Committee (formerly Medical Policy Committee) reviewed and approved additional customizations to the 2013 Edition of the InterQual Criteria. New document for to McKesson InterQual Criteria The 2013 Edition of the InterQual Criteria and corresponding Customized Criteria will take effect May 1, Issue Date: December 19, 2013 Page 30 of 30