Clinical Review Criteria

• Lab Management - Genetic Testing | Prior Authorized Utilization Review | Lab Management (evicore.com)
• Radiology/Cardiology/US - Cardiology Solution | Cardiology Benefit Management | eviCore
• Medical Oncology - Medical Oncology Solution | Evidence-based Clinical Guidelines | eviCore
• Radiation Oncology - Radiation Oncology (evicore.com)
• Sleep Management - Sleep Apnea Treatment | Sleep Apnea PAP Therapy Support | eviCore
• Musculoskeletal Advanced Procedures - Musculoskeletal Solution | Evidence-based Medicine | eviCore
• Musculoskeletal Therapies - Musculoskeletal Solution | Evidence-based Medicine | eviCore
• Peripheral Vascular Intervention Guidelines | eviCore
• eviCore Supplemental Guidelines Resource Document and CMS Policy Hierarchies

InterQual^® Criteria Access

FirstCarolinaCare uses medical necessity criteria based on published clinical evidence to make utilization and prior authorization decisions. Use of the InterQual^® clinical decision support solution is one of the ways we help our provider partners deliver evidence-based appropriate care. Our aim in sharing these criteria is to provide our provider partners with this reference resource to review coverage criteria for prior authorization requests. This resource is intended to help providers and members better understand our decisions and how they align with current medical evidence.

If you are not a member of the FirstCarolinaCare Health Plan or a Participating provider, you can access InterQual^® criteria through this portal You can search for a specific guideline or use codes or keywords to locate information. 

Useful Websites

• American Academy of Pediatrics
• National Heart, Lung, and Blood Institute
• United States Preventive Services Task Force
• UpToDate

Alcohol and Substance Use Disorders

• American Society of Addiction Medicine (ASAM) - National Practice Guideline For the Treatment of Opioid Use Disorder – Focused Update (2020)
• ASAM - ASAM National Practice Guideline on Alcohol Withdrawal Management (2020)
• American Society of Addiction Medicine (ASAM) Criteria for Substance Use Disorder (SUD)

Appropriate Antibiotic Use

• CDC - Centers for Disease Control & Prevention (CDC) – see Antibiotic Prescribing and Use
• Choosing Wisely – see various guidelines re: antibiotic usage
• Infectious Diseases Society of America (IDSA) and SHEA: Guidelines for implementing an antibiotic stewardship program (2016)
• American Academy of Pediatrics (AAP): Red Book – Antimicrobial stewardship (2021) (requires subscription)

Asthma

• National Heart, Lung, and Blood Institute (NHLBI) - Focused update to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group (2020)
• At-A-Glance Guide to the 2020 Focused Updates

ADHD

• American Academy of Pediatricians (AAP) - ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescent (2019)

Chronic Obstructive Pulmonary Disease (COPD)

• 2023 GOLD Report – Global Strategy for Prevention, Diagnosis and Management of COPD

Depression

• American Psychiatric Association (APA) Practice Guideline: Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 3rd edition (2010)
• APA - Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts (2019, Am Psychological Assoc)
• Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol 2015; 29:459

Diabetes

• American Diabetes Association - Standards of Medical Care in Diabetes (2023)

Hypertension

• 2017 ACC/AHA/AAPA/ABC/APCM/AGS/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
• European Society of Cardiology (ESC)/European Society of Hypertension (ESH): Guidelines for the management of arterial hypertension (2018)
• Diagnosis and Management of Atrial Fibrillation
  2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

Osteoporosis

• US Preventive Services Task Force (USPSTF): Osteoporosis to Prevent Fractures, Screening (2018)

Potentially Inappropriate Medication Use in Older Adults

• American Geriatrics Society - 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults

Preventive Care

• USPSTF Recommendations

Tobacco Use

• USPSTF: Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions
• USPSTF: Prevention and Cessation of Tobacco Use in Children and Adolescents: Primary Care Interventions

Weight Management

• USPSTF - Final recommendation statement – Weight loss to prevent obesity-related morbidity and mortality in adults: Behavioral interventions (2018)
• World Gastroenterology Organisation (WGO) - Global guideline on obesity (2011)
• AAP - Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity (2023)

Clinical Guidelines Resources have been developed to assist patients and providers in choosing appropriate healthcare alternatives for specific clinical conditions. Guidelines were developed by nationally recognized organizations and are evidence based. While clinical practice guidelines are useful aids to assist providers in determining appropriate care practices for many of their patients with specific clinical problems or prevention issues, the guidelines are not meant to replace the clinical judgment of the individual physician or establish a standard of care. Note, recommended services in association with the clinical guidelines are not a direct reflection of insurance coverage. Coverage for services is subject to the limitations specified in the member's benefit plan.

The recommendations contained in the guidelines may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the provider in light of the circumstances presented by the individual patient. Accordingly, your health plan makes and receives no warranty, express nor implied, and all warranties of merchantability and fitness for a particular purpose are expressly excluded