InterQual Criteria for Bunionectomy

Harvard Pilgrim currently requires prior authorization for commercial bunionectomy procedures, and for dates of service beginning on Sept. 25, 2020, we will adopt InterQual criteria for medical review.

In addition to the codes currently requiring prior authorization, the following CPT codes will be added to the policy and will require prior authorization:

  • 28289 –Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant
  • 28291 –Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint;
  • 28299 –Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any method
  • 28306 –Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal
  • 28310 –Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure)
  • 28750–Arthrodesis, great toe; metatarsophalangeal joint

With the adoption of InterQual criteria, when submitting your authorization request through HPHConnect, electronic authorization questionnaires —which will replace the existing Bunionectomy Prior Authorization Request Form —will guide you through the criteria. For guidance on using HPHConnect to request an authorization and accessing the InterQual criteria, refer to this training presentation. To request additional training, contact us at Provider_Experience@harvardpilgrim.org.

For more information, please refer to the updated Bunionectomy Medical Policy. You may view and print the following SmartSheet questionnaires via HPHConnect (go to www.harvardpilgrim.org/providerportal, select Resource Center and then the Upcoming InterQual link).

Publication Information

Helen Connaughton,
Director, Network Operations

Annmarie Dadoly,
Editor

Joseph O’Riordan,
Writer

Kristin Edmonston,
Production Coordinator