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Clinical criteria have moved or been retired
April 2, 2021

On April 1, 2021, we reorganized some of the information on our Provider Central Clinical Resources page. We told you about these changes in our January 11, 2021 news article where we announced April 2021 Medical and Pharmacy Policy updates. We:

  1. Moved clinical criteria shown below to our Medical Policy site. You can search by the policy number or name to easily find them.
    New policy # Policy name
    142 Air ambulance*
    146 Ground ambulance
    158 Outpatient pediatric pain rehabilitation centers

    *Federal Employee Program guidelines for air ambulance will remain on the Coverage Criteria & Guidelines page in Provider Central.

  2. Transitioned the following guidelines to InterQual® Criteria. To access the criteria, you can log in and go to Clinical Resources>InterQual® Criteria & SmartSheets:
    For Use this InterQual subset
    Crisis stabilization Residential crisis program
    Family stabilization Intensive outpatient (IOP)*
    Private duty nursing Private duty nursing

    *If you are looking for Intensive Community Based Treatment (ICBT), please see the ICBT subset.

  3. Retired our medical necessity criteria for:
    •  Outpatient Chest PT
    •  PT/OT Medical Necessity – Vestibular Rehabilitation

Please note that any information pertaining to the Federal Employee Program (FEP) is still available under Coverage Criteria & Guidelines.