InterQual criteria Form

ADMINISTRATIVE GUIDELINE – 10.01.530 Services Reviewed Using InterQual Criteria Effective Date: Mar. 4, 2026 Last Revised: Feb. 23, 2026 Replaces: N/A RELATED MEDICAL POLICIES:
1.01.508 Negative Pressure Wound Therapy (NPWT) Devices in Adults 2.02.517 Electrophysiology (EP) studies 7.01.44 Implantable Cardioverter Defibrillator (ICD insertion) 7.01.601 Endovascular Stent Grafts for Abdominal Aortic Aneurysms 7.01.602 Shoulder Arthroscopy in Adults 7.01.605 Shoulder Arthrotomy in Adults

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Introduction The Plan uses InterQual to review certain services for medical necessity as listed in this guideline. InterQual is evidence-based criteria that offers guidance in covering medical and behavioral health for all levels of care in addition to care planning, complex care management, durable medical equipment, procedures, and specialty pharmacy.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Administrative Guideline

Medical Necessity The following services are considered medically necessary when criteria are met using InterQual criteria: Module Service 10.01.530_PBCInd (02-23-2026)

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∞ Medical Necessity Acute Adult • Acute Kidney Injury • Anemia/Bleeding • Antepartum • Asthma • Capsule endoscopy • Capsule Endoscopy, Colon • Capsule Endoscopy, Small Bowel or Esophageal
• Carbon Monoxide Poisoning • Cholecystitis • Chronic Obstructive Pulmonary Disease (COPD) • Cystic Fibrosis • Deep Vein Thrombosis • Diabetes Mellites (DM) • Diabetic Ketoacidosis (DKA) • Electrolyte/Mineral Imbalance • Epilepsy • Extended Stay • General Medical • General Trauma • Heart Failure • Hematology/Oncology: Acute Myeloid Leukemia • Hematology/Oncology: Brain Malignancy/Metastasis • Hematology/Oncology: Chemo • Hematology/Oncology: Hemolytic Uremic Syndrome • Hematology/Oncology: Malignant Disease • Hematology/Oncology: Tumor Lysis Syndrome • Hip arthrotomy • Hyperosmolar Hyperglycemic State • Hypertension • Hypertensive Disorder in Pregnancy • Hypoglycemia • Infection: Central Nervous System (CNS) • Infection: Endocarditis • Infection: General • Infection: Gastrointestinal/Genitourinary/Gynecology • Infection: Musculoskeletal • Infection: Pneumonia

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∞ Medical Necessity • Infection: Sepsis • Infection: Skin • Irritable Bowel Disease • Labor & Delivery • Pancreatitis • Postpartum Complications After Discharge • Pulmonary Embolism • Quality Indicator Checklist • Rhabdomyolysis or Crush Syndrome • Sickle Cell Crisis • Stroke • Syncope • Total Joint Replacement (TJR) Ankle
• Transient Ischemic Attack (TIA) • Transition Plan (Continued Stay and Transition Planning only) • Withdrawal Syndrome • Wound debridement Acute Pediatrics • Acetaminophen Overdose • Acute Kidney Injury • Anemia/Bleeding • Antepartum • Asthma • Brief Unresolved Unexplained Event • Bronchiolitis • Capsule Endoscopy (Pediatric) • Carbon Monoxide Poisoning • Cellulitis • Croup • Cystic Fibrosis • Dehydration/Gastroenteritis • Diabetic Ketoacidosis (DKA) • Diabetes Mellites (DM) • Electrolyte/Mineral Imbalance • Epilepsy • Extended Stay • Failure to Thrive

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∞ Medical Necessity • General Medical • General Trauma • Hematology/Oncology: Chemotherapy • Hematology/Oncology: Acute Leukemia • Hematology/Oncology: Brain Malignancy/Metastasis • Hematology/Oncology: Hemolytic Uremic Syndrome • Hematology/Oncology: Malignant Disease • Hematology/Oncology: Tumor Lysis Syndrome • Hip Arthrotomy • Hyperbilirubinemia • Hypertensive Disorder in Pregnancy • Hypoglycemia • Infection: Central Nervous System (CNS) • Infection: Endocarditis • Infection: General • Infection: Gastrointestinal/Genitourinary/Gynecology • Infection: Meningitis • Infection: Musculoskeletal • Infection: Pneumonia • Infection: Pyelonephritis • Infection: Sepsis • Infection: Skin • Labor & Delivery • Nursery • Pancreatitis • Postpartum Complications After Discharge • Quality Indicator Checklist • Rhabdomyolysis or Crush Syndrome • Sickle Cell Crisis • Transition Plan (Continued Stay and Transition Planning only) • Withdrawal Syndrome • Wound Debridement Behavioral Health • Adult and Geriatric Psychiatry • Applied Behavior Analysis for Autism Spectrum Disorder • Child and Adolescent Psychiatry • Electroconvulsive Therapy: Adolescent

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∞ Medical Necessity • Electroconvulsive Therapy: Adult/Geriatric • Neurobehavioral Status Exam • Neuropsychological Testing • Neuropsychological Testing: Pediatric • Pharmacogenomic Testing for Psychotropic Medication Drug Response • Psychological Testing • Stereotactic Introduction: Subcortical Electrodes • Substance Abuse Disorders Durable Medical Equipment (DME) • Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology
• Home Mechanical Ventilation Devices: Invasive, Noninvasive, and Multifunction
• Home Oxygen Therapy
• Orthosis, Spinal (Thoracolumbosacral) Home Care • Adult and Pediatric Long Term Acute Care (LTAC) • Medically Complex • Respiratory Complex • Transition Plan • Ventilator Weaning • Wound/Skin Procedures • Mastectomy, Prophylactic, Total or Simple
• Osteotomy, Proximal, First Metatarsal (MT) (Bunionectomy) • Prostatectomy, Radical • Salpingectomy
• Salpingo-Oophorectomy, Bilateral, Oophorectomy, Bilateral • Salpingo-Oophorectomy, Unilateral, Oophorectomy, Unilateral • Tendon Sheath Incision or Excision, Hand, Flexor • Video Electroencephalographic (EEG) Monitoring Rehabilitation • Amputation, Lower Extremity Rehabilitation (Adult, Adolescent, School Age) • Amputation, Upper Extremity Rehabilitation (Adult, Adolescent, School Age) • Cardiac Rehabilitation (Adult) • Carpal Tunnel Syndrome Rehabilitation (Adult)

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∞ Medical Necessity • Cerebrovascular Accident Rehabilitation (Adult) • DeQuervain’s Tenosynovitis Rehabilitation (Adult) • Fractures, Lower Extremity (Adult, Adolescent, School Age) • Fractures, Upper Extremity Rehabilitation (Adult, Adolescent, School Age) • General Deconditioning Rehabilitation (Adult) • Habilitation (Adult, Adolescent, School Age) • Habilitation Criteria • Instability Dislocation Shoulder Rehabilitation (Adult) • Ligamentous Injury Ankle Rehabilitation (Adult, Adolescent, School Age) • Ligamentous Injury Knee Rehabilitation (Adult, Adolescent, School Age) • Lymphedema Rehabilitation (Adult) • Maintenance Therapy Rehabilitation (Adult) • Meniscal Injury Knee Rehabilitation (Adult, Adolescent, School Age) • Multiple Sclerosis Rehabilitation (Adult) • Osteoarthritis Hip Rehabilitation (Adult) • Osteoarthritis Rehabilitation, Knee (Adult) • Osteoarthritis Rehabilitation, Shoulder (Adult) • Pain Syndromes Rehabilitation (Adult, Adolescent) • Pediatric Rehabilitation Criteria • Pelvic Floor Rehabilitation • Pulmonary Rehabilitation (Adult) • Rotator Cuff Disorders Rehabilitation (Adult, Adolescent, School Age) • Soft Tissue Disorders Knee Rehabilitation (Adult, Adolescent, School Age) • Soft Tissue Disorders Rehabilitation, Foot and Ankle (Adult Adolescent, School Age) • Soft Tissue Disorders, Rehabilitation (Adult) • Spinal Disorders Rehabilitation, Cervical (Adult) • Spinal Disorders Rehabilitation, Lumbar (Adult, Adolescent, School Age) • Sprain Wrist Rehabilitation (Adult, Adolescent, School Age)

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∞ Medical Necessity • Strain Low Back Rehabilitation (Adult, Adolescent, School Age) • Strain Neck Rehabilitation (Adult, Adolescent, School Age) • Tendon Injury Hand Rehabilitation (Adult, Adolescent, School Age) • Tendon Rupture Achilles Rehabilitation (Adult) • Thoracic Outlet Syndrome Rehabilitation (Adult, Adolescent, School Age) • Traumatic Brain Injury Rehabilitation (Adult) • Trigger Finger Rehabilitation (Adult) • Ulnar Neuropathy Rehabilitation (Adult, Adolescent, School Age) Specialty Rx Non- Oncology • Alpha 1 Proteinase Inhibitor • Bevacizumab Intravitreal • Factor Ix (Alphanine Sd) • Factor Ix (Bebulin Vh, Profilnine Sd) • Factor Ix (Benefix, Rixubis) • Factor Viii (Advate) • Factor Viii (Alphanate) • Factor Viii (Hemofil M) • Factor Viii (Humate-P) • Factor Viii (Wilate) • Factor Viii (Xyntha) • Factor Viii or Ix (Feiba Nf) • Factor Xiii (Corifact) • Hydroxyprogesterone Caproate • Lanreotide • Octreotide Acetate (Sandostatin Lar Depot) • Octreotide Acetate (Sandostatin) • Rho(D) Immune Globulin (Rhophylac) • Rho(D) Immune Globulin (Winrho) Specialty Rx Oncology • Plerixafor
• Rolapitant Injection • Zoledronic Acid Subacute/Skilled Nursing Facility • Maintenance Therapy

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∞ History

Date Comments 09/16/19 New administrative guideline, approved August 30, 2019, effective January 1, 2020, developed to aid in navigation to InterQual clinical criteria for use in the individual market.
10/22/19 Minor update, the policy was corrected to remove drugs that will not be addressed using InterQual criteria. These had been added in error. 11/21/19 Interim Review, approved November 12, 2019, effective February 21, 2020. Added rehabilitative services to be reviewed using InterQual as listed; considered medically necessary when criteria are met. 12/01/19 Minor update, the policy was corrected to remove additional drugs that will not be addressed using InterQual criteria. These had been added in error. 04/01/20 Interim Review, approved March 10, 2020. The following changes are effective July 2, 2020, following provider notification. Services within durable medical equipment and procedures were added to those reviewed for medical necessity using InterQual criteria for dates of service July 2, 2020, and after. The following policies are no longer effective after that date: 1.01.10, 1.01.11, 1.01.15, 1.01.18, 1.01.30, 1.01.501, 1.01.519, 1.01.520, 1.01.527, 1.03.501, 2.01.40, 2.01.505, 2.01.533, 2.02.09, 2.02.26, 2.02.30, 2.02.506, 2.02.507, 6.01.25, 7.01.05, 7.01.07, 7.01.20, 7.01.107, 7.01.108, 7.01.109, 7.01.132, 7.01.138, 7.01.143, 7.01.503, 7.01.508, 7.01.516, 7.01.519, 7.01.521, 7.01.522, 7.01.523, 7.01.533, 7.01.542, 7.01.546, 7.01.549, 7.01.550, 7.01.551, 7.01.554, 7.01.555, 7.01.558, 7.01.560, 7.01.570, 7.01.573, 7.01.63, 7.01.84, 7.01.87, 7.01.95, 7.03.01, 7.03.09, 7.03.11, 7.03.509, 8.01.11, 8.01.15, 8.01.17, 8.01.21, 8.01.22, 8.01.29, 8.01.30, 8.01.36, 8.01.521, 9.03.01. 05/06/20 Interim Review, approved May 5, 2020. Corrections made: Policies 2.02.09, 7.01.07, 7.01.87, 7.01.95, 7.01.554, 7.03.09, 7.03.11 and 9.03.01 along with corresponding InterQual subsets removed; policies 8.01.529 and 8.01.532 added (subsets were listed but titles were inadvertently not included in reference policies). Autologous stem cell transplant subset added; it was left out in error. 06/09/20 Interim Review, approved June 9, 2020. Correction made policies 2.01.40, 2.01.505, 6.01.25, 7.01.107, 7.01.108, 7.01.109, 7.01.138, 7.01.508, 7.01.516, 7.01.522, 7.01.533, 7.01.542, 7.01.551, 7.01.555, 7.01.560, 7.01.570, 7.03.01, 7.03.509, 8.01.11, 8.01.15, 8.01.17, 8.01.21, 8.01.22, 8.01.29, 8.01.30, 8.01.521, 8.01.529, 8.01.532 along with corresponding InterQual subsets removed. 06/25/20 Interim Review, approved June 25, 2020. Removed policy 2.02.30 – this policy will remain active and InterQual will not replace this review criteria on July 2, 2020.

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∞ Date Comments 11/01/20 Annual Review, approved Oct. 13, 2020. Policy updated to remove outpatient procedures and DME which will no longer be in effect as of Feb. 5, 2021, pursuant to provider notification. 06/01/21 Interim Review, approved May 20, 2021. Removed aflibercept, ranibizumab, and reslizumab from Specialty Rx Non-Oncology. 08/01/21 Annual Review, approved July 9, 2021. Policy reviewed; no changes. 09/01/22 Interim Review, approved August 9, 2022. Removed botulinum toxins from Pharmacy Specialty Rx Non-Oncology section. These drugs will now be reviewed with policy 5.01.512 Botulinum Toxins effective December 1, 2022. 10/01/22 Annual Review, approved September 26, 2022. Added Negative Pressure Wound Therapy to the DME section; added Capsule Endoscopy to acute Adult and Pediatric Acute sections replacing policies 1.01.532 Negative Pressure Wound therapy and 2.01.538 Capsule Endoscopy. Added Total Ankle Replacement to Adult Acute section to replace policy 7.01.577 Total Ankle Replacement; and added Electroconvulsive Therapy, both effective January 6, 2023 following 90-day provider notification. 01/01/23 Interim Review, approved December 13, 2022. Added Cardiac Defibrillator, Subcutaneous Implantable, Home Oxygen Therapy, and Spinal Orthosis to the list of services reviewed using InterQual criteria. 08/01/23 Annual Review, approved July 11, 2023. Added Endovascular Repair, Abdominal Aortic Aneurysm (AAA) and Mastectomy, Prophylactic, Total or Simple to the list of services reviewed using InterQual criteria to replace policies 2.02.513 Endovascular Repair- Stent for Abdominal Aortic Aneurysm and 7.01.581 Prophylactic Mastectomy. 09/01/23 Interim Review, approved August 8, 2023. Added Digital Breast Tomosynthesis to the list of services reviewed using InterQual criteria to replace policy 6.01.526 Digital Breast Tomosynthesis effective December 7, 2023 following 90-day provider notification. 12/07/23 Minor corrections. Corrected module listed under Imaging to, “Imaging, Breast” which replaced policy 6.01.526, Digital Breast Tomosynthesis” (incorrectly listed as “Digital Breast Tomosynthesis”). Also, corrected module name for Spinal Stenosis to “Orthosis, Spinal (Thoracolumbosacral).” Moved “Cardiac Defibrillator, Subcutaneous Implantable” from the Adult Acute section to the Procedures section and correctly listed as, “Implantable Cardioverter Defibrillator (ICD Insertion).” 01/01/24 Interim Review, approved December 12, 2023. Added salpingo-oophorectomy, bilateral and unilateral; and salpingo, unilateral and bilateral, to the Procedures section replacing policy 7.01.580, Prophylactic Bilateral Salpingo-Oophorectomy as of January 1, 2024.
09/01/24 Annual Review, approved August 13, 2024. Removed imaging, breast, as these services are not reviewed. Added the following subsets to be effective for dates of service on or after December 5, 2024, following 90-day notification: Arthrotomy, Shoulder Arthroscopy or Arthroscopically Assisted Surgery, Shoulder; Arthrotomy, Shoulder; Electrophysiology (EP) Testing +/- Radiofrequency (RFA) or Cryothermal

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∞ Date Comments Ablation, Cardiac; Osteotomy, Proximal, First Metatarsal (MT) (Bunionectomy); Prostatectomy, Radical; Salpingectomy; Tendon Sheath Incision or Excision, Hand, Flexor; and, Video Electroencephalographic (EEG) Monitoring. 12/13/24 Minor correction made to format. 11/01/25 Annual Review, approved October 27, 2025. Removed implantable cardioverter defibrillator (ICD insertion); this is now referenced in policy 7.01.44 Implantable Cardioverter Defibrillator (ICD insertion). No other changes. 12/04/25 Interim Review, approved November 24, 2025. Removed negative pressure wound therapy from the list of services reviewed using InterQual criteria. This service will be reviewed using policy 1.01.508 Negative Pressure Wound Therapy (NPWT) Devices in Adults, for dates of service December 4, 2025, and after. 02/06/26 Interim Review, approved January 26, 2026. Removed shoulder arthroscopy or arthroscopically assisted surgery, shoulder from the list of services reviewed using InterQual criteria. This service will be reviewed using policy 7.01.602 Shoulder Arthroscopy in Adults, for dates of service effective February 6, 2026, and after. 03/04/26 Interim Review, approved February 23, 2026. Removed InterQual modules shoulder arthrotomy, electrophysiology (EP) testing, and endovascular repair, abdominal aortic aneurysm (AAA). These procedures will be reviewed with the following policies effective for dates of service March 4, 2026, and after: 7.01.605 Shoulder Arthrotomy in Adults, 2.02.517; Electrophysiology (EP) Studies; and, 7.01.601 Endovascular Stent Grafts for Abdominal Aortic Aneurysms.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2026 Premera All Rights Reserved. Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy only applies to Individual plans.