InterQual Criteria for Implantable Neurostimulators

Beginning on Sept. 25, 2020, Harvard Pilgrim will be adopting customized InterQual criteria for commercial medical review of implantable neurostimulators. Prior authorization will continue to be required, but we will draw upon a combination of InterQual and Harvard Pilgrim criteria.

With the adoption of InterQual criteria, prior authorization will be required for CPT code 63663 (Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed).

When submitting your authorization request through HPHConnect, electronic authorization questionnaires 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 While Harvard Pilgrim encourages providers to request authorization electronically, we will continue to accept authorization requests by phone (800-708-4414) or fax (800-232-0816).

In addition, the following CPT and HCPCS codes will be added to the policy, and will be covered without prior authorization: 95980, 95981, 95982, C1767, C1778, C1820, L8679, L8680, L8682, L8683, L8686, L8687, and L8688.

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).