Medical necessity: InterQual, MCG and payer policy

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When a reviewer evaluates a request, they are applying criteria: a written standard describing what clinical facts support a given service. Those criteria are usually knowable in advance. Practices that read them before submitting write different requests from practices that do not.

#The three sources

Licensed criteria sets: InterQual, from Change Healthcare, and MCG, formerly Milliman Care Guidelines, are the two widely licensed commercial criteria sets. Plans license them and apply them to categories of service. They are evidence-based, updated periodically, and proprietary, which means a practice usually sees them through the plan rather than directly.
The plan's own medical policy: Most plans publish medical policies or coverage determinations for specific services, on their provider site, with an effective date and usually a bibliography. Where a plan has its own policy it generally takes precedence over the licensed set. These are public and specific and they are the most underused resource in the process.
Regulatory coverage rules: For Medicare Advantage, CMS national and local coverage determinations constrain what a plan may require. A plan cannot be more restrictive than Medicare on a service Medicare covers, which is a genuine and often forgotten lever.

The highest-yield habit in prior authorization

Before submitting for a service your practice does frequently, read the plan's published policy for it once. Not per request; once. Learn what the criteria actually require, then make sure the documentation you routinely capture contains those elements. Most repeat denials in a specialty practice are a handful of policies whose requirements nobody read.

#What criteria usually ask for

Patterns recur across services and across plans:

Conservative management first. What was tried, for how long, and what happened. Duration matters and is frequently the element that is missing.
Objective findings, not just symptoms. Imaging, laboratory values, measured function, validated scores.
A documented indication that matches the code. The diagnosis on the request has to be the diagnosis the policy is written against.
Failure or contraindication of the cheaper alternative, where one exists.
Timing. Some services have minimum intervals, and a surveillance procedure requested early will be denied on interval alone regardless of how good the rest of the case is.

#Criteria are a floor, not a ceiling

Meeting published criteria makes approval likely, not certain, and failing them is not the end. A patient who does not meet standard criteria may still warrant the service, and that is what a peer-to-peer discussion exists for. The criteria tell you which argument you are having: whether you are demonstrating that the patient meets the standard, or explaining why the standard does not fit this patient.

Those are different letters. Writing the second when you needed the first, or the reverse, is a common and avoidable waste.