InterQual for Invasive Treatment for Urinary Incontinence

Beginning on Nov. 1, 2020, Harvard Pilgrim will be adopting customized InterQual criteria for commercial medical review of invasive treatment for urinary incontinence.

Harvard Pilgrim currently requires prior authorization for invasive treatment for urinary incontinence, and the prior authorization criteria for artificial urinary sphincter surgery and periurethral bulking agents will remain on the policy. However, with the adoption of InterQual criteria, we will also require prior authorization for CPT code 57289 (Pereyra procedure, including anterior colporrhaphy). In addition, the following codes will be removed from the policy and will no longer require prior authorization:

  • 53442 – Removal or revision of sling for male urinary incontinence (e.g. fascia or synthetic)
  • 53446 – Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff
  • 53447 – Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session
  • 53448 – Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue
  • 53449 – Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff
  • 57287 – Removal or revision of sling for stress incontinence (e.g., fascia or synthetic)

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 Provider_Experience@harvardpilgrim.org. 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).

For more information, please refer to the updated Invasive Treatment for Urinary Incontinence Medical Policy. You may view and print the applicable SmartSheet questionnaires via HPHConnect (go to www.harvardpilgrim.org/providerportal, select Resources and then the Upcoming InterQual link).