Implantable Neurostimulators InterQual Criteria Updates

Effective for dates of service beginning Aug. 27, 2021, Harvard Pilgrim is updating our commercial Implantable Neurostimulators Medical Policy.

The policy utilizes a combination of InterQual and Harvard Pilgrim 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:

  • Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; globus pallidus or thalamus (CPT code 61720)
  • Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of attendance by a physician or other qualified health care professional (CPT code 95961)

Furthermore, Harvard Pilgrim will no longer require prior authorization for the services indicated by CPT codes 95970, 95971, and 95972, related to electronic analysis of implanted neurostimulator pulse generator system.

For more information, please refer to the updated Implantable Neurostimulators 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

Helen Connaughton,
Director, Network Operations

Annmarie Dadoly,

Joseph O’Riordan,

Kristin Edmonston,
Production Coordinator