InterQual® DME criteria for medical decision-making

InterQual® DME criteria are used by the Authorization team to assist them in determining coverage for durable medical equipment. Priority Health chose InterQual®

DME criteria to ensure decision-making consistency and medical necessity.

InterQual® DME criteria are a first level screening tool to assist in determining if the proposed equipment is clinically indicated or whether further evaluation is required. The first level screening is done by the nurse. If the criteria are met, the case is approved; if the criteria are not met, the case is referred to the associate vice president of medical affairs and/or a medical director. InterQual® DME criteria cannot be used to deny equipment. Only physicians can determine clinical appropriateness.

Priority Health also recognizes that the criteria can never address all the issues; criteria cannot apply to every patient in every situation. Use of the criteria never replaces clinical judgment.

The InterQual® DME criteria are reviewed and approved annually by the associate vice president of medical affairs and Medical Affairs Committee.