Medicaid Claim – InterQual Criteria

By: Derek Hawkins//May 18, 2020//

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WI Court of Appeals – District III

Case Name: Samuel Ison v. Department of Health Services and Division of Medicaid Services

Case No.: 2018AP2260

Officials: Stark, P.J., Hruz and Seidl, JJ.

Focus: Medicaid Claim – InterQual Criteria

Samuel Ison appeals an order denying his WIS. STAT. ch. 227 (2017-18) appeal from the administrative denial of a Medicaid claim. Ison challenges his health maintenance organization’s (HMO) use of InterQual criteria to deny his requested prior authorization for back surgery and a decision by the Department of Health Services to uphold the denial of the prior authorization request as medically unnecessary. We conclude Ison forfeited the first issue regarding the use of InterQual criteria and there is substantial evidence in the record to support the Department’s decision. We therefore affirm.

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Derek A Hawkins is trademark corporate counsel for Harley-Davidson. Hawkins oversees the prosecution and maintenance of the Harley-Davidson’s international trademark portfolio in emerging markets.

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