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
- Sex 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. WPATH criteria are listed here: https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644
Additional Information and Resources
Medicare Prior Authorization list:
mclarenhealthplan.org/Uploads/Public/Documents/HealthPlan/documents/Medicare/MHP_Medicare_PriorAuthorizationList.pdf
Utilization Management Annual Reporting
The Centers for Medicare and Medicaid Services (CMS) requires health plans to publish certain utilization data on their website for members and providers. Utilization data is related to how quickly we process authorization requests. The required data is presented in the table below: (2025 Data Coming Soon)
| Item |
Calendar Year
2025 |
| Total standard prior authorization requests received |
|
| Total expedited prior authorization requests received |
|
| Total standard and expedited prior authorization requests received |
|
| Percentage of standard prior authorization requests that were approved |
|
| Percentage of standard prior authorization requests that were denied |
|
| Percentage of standard prior authorization requests approved after appeal |
|
| Average time to decision for standard prior authorizations |
|
| Median time to decision on standard prior authorizations |
|
| Percentage of expedited prior authorization requests that were approved |
|
| Percentage of expedited prior authorization requests that were denied |
|
| Average time to decision for expedited prior authorizations |
|
| Median time to decision for expedited prior authorizations |
|
| Percentage of total prior authorization requests approved with an extended timeframe |
|