Medical Necessity and Clinical Criteria

McLaren Medicare partners with InterQual® to create clinical criteria or standards to determine the medical necessity and appropriateness of health care services.

Clinical criteria help ensure that health care services are evidence based and objective. Clinical criteria are not used to deny care. Clinical criteria can help improve health outcomes and may also help reduce the cost of services.

The following procedures are subject to InterQual clinical criteria guidelines. Refer to InterQual® for the below clinical criteria guidelines... https://prod.ds.interqual.com/service/connect/transparency?tid=dc31b123-941a-4127-a79e-44d2eb3980d5

  • Abdomen CT scan with/without contrast
  • Bariatric revision
  • CardioMems
  • Electrical Stimulation
  • Entropion Repair
  • Erector Spine Block
  • External wearable defibrillator
  • Gender Reassignment/Affirmation*
  • Heart (cardiac) cath
  • Intracranial neurostimulator electrode removal/replacement
  • Keratoplasty corneal transplant
  • Nuclear Medicine Myocardial Perfusion Study (rest/stress scan)
  • Outpatient therapy (Physical, Occupational, and Speech Therapies)
  • Panniculectomy/Abdominoplasty
  • Pelvis CT scan with/without contrast
  • Peroral Endoscopic Myotomy
  • Transthoracic Echocardiography

*World Professional Association for Transgender Health (WPATH) criteria may be used in addition to InterQual criteria for gender reassignment/affirmation. WPATH criteria are listed here: https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644