Internal Coverage Criteria for Medical Services

When reviewing a prior authorization request, Devoted Health uses InterQual™ clinical criteria for the services and procedures listed in this policy: Services reviewed using InterQual criteria (PDF)

See InterQual’s detailed coverage criteria. (Note: you'll need to create an Optum One Healthcare ID account to access the criteria.)

Learn about InterQual’s development process (PDF)

For cases when coverage criteria are not fully spelled out in these resources, we created internal coverage criteria based on current evidence in widely used treatment guidelines or in publicly available clinical literature.

Medical Services

Barostim Neo Device

Cardiac Catheterization & Coronary Angiography Clinical Criteria

Cardiac Transplantation

CardioMEMS HF System

COC Out-of-Network Dialysis

Galleri® Test by Grail Labs Technology Assessment

Home Health Services

Home Infusion Therapy Services

Insertable Cardiac Monitors

Intraosseous Nerve Ablation Technology Assessment

Liver Fibrosis Testing

Lung Transplant

Minimal Residual Disease Testing for Cancer

MyoPro Orthotic Device Technology Assessment

Readmission Policy

Renal Transplant

Replacement/Repair DME

Superion Interspinous Spacer System Technology Assessment

Tilt Table Testing

Ventricular Assist Device Technology Assessment