Bariatric Surgery InterQual Criteria Updates

Effective for dates of service beginning Nov. 1, 2021, Harvard Pilgrim is updating our commercial Bariatric Surgery Medical Policy.

The policy utilizes InterQual criteria for medical review, and some of the associated InterQual SmartSheets will be updated or migrated to new 2021 SmartSheets. In addition, the following services will be added to the policy and will require prior authorization:

  • 43850 – Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy
  • 43855 – Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; with vagotomy

For more information, please refer to the updated Bariatric Surgery Medical Policy. You may view and print the applicable SmartSheet questionnaires via HPHConnect (go to, select Resources and then the Upcoming InterQual link).

Publication Information

Annmarie Dadoly,

Joseph O’Riordan,

Kristin Edmonston,
Production Coordinator