{"openapi":"3.1.0","info":{"title":"Documentation Templates and Rules","description":"Facade REST APIs for Documentation Templates and Rules (DTR) workflows. This specification fully documents all four DTR stages: documentation-requirements, questionnaire-package, next-question, and generate-guidance.","version":"1.0.0"},"servers":[{"url":"https://sandbox-apigw.optum.com/abm","description":"OI API Gateway - Dev"}],"tags":[{"name":"DTR API","description":""}],"x-readme":{"explorer-enabled":true,"proxy-enabled":true},"security":[{"bearerAuth":[]}],"paths":{"/dtr/v1":{"post":{"description":"Accepts a FHIR DTR request and returns a FHIR response.\n\nUse the `stage` query parameter to select the workflow step. If `stage` is omitted, the default is `questionnaire-package`.\n\nRecommended call sequence:\n1. `documentation-requirements` - Check whether documentation is required for the submitted coverage and order(s).\n2. `questionnaire-package` - Retrieve PackageBundle containing `Questionnare` and `QuestionnaireResponse`.\n3. `next-question` - Submit an in-progress `QuestionnaireResponse` to get the next question(s). Repeat until status is `completed`.\n4. `generate-guidance` - Submit one or more completed `QuestionnaireResponse` resources to produce final documentation/guidance.","operationId":"handleIqxDtrRequest","parameters":[{"description":"Execution stage. Selects which of the four DTR operations is executed and determines the expected request/response payload shape (see the operation description and the request examples for each stage). This is Optional - when it is not provided, the backend defaults to `questionnaire-package`.","in":"query","name":"stage","required":false,"schema":{"type":"string","enum":["documentation-requirements","questionnaire-package","next-question","generate-guidance"],"default":"questionnaire-package"}}],"requestBody":{"content":{"application/fhir+json":{"schema":{"type":"string","description":"FHIR payload, sent as raw JSON text. Shape depends on the `stage` query parameter: a FHIR `Parameters` resource (containing `coverage` + `order`, `coverage` + `context`, or `coverage` + `questionnaire` canonical entries) for `documentation-requirements` and `questionnaire-package`, a FHIR `QuestionnaireResponse` resource for `next-question`, and a FHIR `Parameters` resource containing one or more `questionnaireResponse` entries for `generate-guidance`. Server-side, this is received and passed through as a raw JSON string without deserialization into a typed object."},"examples":{"Documentation Requirements - Success":{"summary":"documentation-requirements: coverage + order","description":"Determines whether documentation is required for the given coverage and order.","value":"{\n \"resourceType\": \"Parameters\",\n \"parameter\": [\n {\n \"name\": \"patient\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"PatientExampleId\",\n \"name\": [\n {\n \"family\": \"Doe\",\n \"given\": [\n \"Jane\"\n ]\n }\n ],\n \"gender\": \"female\",\n \"birthDate\": \"1985-10-15\"\n }\n },\n {\n \"name\": \"coverage\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"beneficiary\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"extension\": [\n {\n \"extension\": [\n {\n \"extension\": [\n {\n \"url\": \"key\",\n \"valueString\": \"LineOfBusiness1\"\n },\n {\n \"url\": \"contents\",\n \"valueString\": \"medicare\"\n }\n ],\n \"url\": \"lineOfBusinessN\"\n }\n ],\n \"url\": \"https://payer-crd.s3docs.optum.com/StructureDefinition/interqual-line-of-business\"\n }\n ]\n }\n },\n {\n \"name\": \"order\",\n \"resource\": {\n \"resourceType\": \"DeviceRequest\",\n \"codeCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.ama-assn.org/go/hcpcs\",\n \"code\": \"42831\"\n }\n ],\n \"text\": \"adenoidectomy\"\n }\n }\n }\n ]\n}"},"Questionnaire Package - Orders":{"summary":"questionnaire-package: coverage + orders","description":"Retrieves the questionnaire(s) needed for each of the supplied orders. order.id is optional.","value":"{\n \"resourceType\": \"Parameters\",\n \"parameter\": [\n {\n \"name\": \"patient\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"PatientExampleId\",\n \"name\": [\n {\n \"family\": \"Doe\",\n \"given\": [\n \"Jane\"\n ]\n }\n ],\n \"gender\": \"female\",\n \"birthDate\": \"1985-10-15\"\n }\n },\n {\n \"name\": \"coverage\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"beneficiary\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"extension\": [\n {\n \"extension\": [\n {\n \"extension\": [\n {\n \"url\": \"key\",\n \"valueString\": \"LineOfBusiness1\"\n },\n {\n \"url\": \"contents\",\n \"valueString\": \"medicare\"\n }\n ],\n \"url\": \"lineOfBusinessN\"\n }\n ],\n \"url\": \"https://payer-crd.s3docs.optum.com/StructureDefinition/interqual-line-of-business\"\n }\n ]\n }\n },\n {\n \"name\": \"order\",\n \"resource\": {\n \"resourceType\": \"DeviceRequest\",\n \"codeCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.ama-assn.org/go/hcpcs\",\n \"code\": \"42831\"\n }\n ],\n \"text\": \"adenoidectomy\"\n }\n }\n }\n ]\n}"},"Questionnaire Package - Context Id":{"summary":"questionnaire-package: coverage + issued context id","description":"Re-uses a processingContextId returned by a prior documentation-requirements or questionnaire-package call instead of re-supplying the order(s).","value":"{\n \"resourceType\": \"Parameters\",\n \"parameter\": [\n {\n \"name\": \"patient\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"PatientExampleId\",\n \"name\": [\n {\n \"family\": \"Doe\",\n \"given\": [\n \"Jane\"\n ]\n }\n ],\n \"gender\": \"female\",\n \"birthDate\": \"1985-10-15\"\n }\n },\n {\n \"name\": \"coverage\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"beneficiary\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"extension\": [\n {\n \"extension\": [\n {\n \"extension\": [\n {\n \"url\": \"key\",\n \"valueString\": \"LineOfBusiness1\"\n },\n {\n \"url\": \"contents\",\n \"valueString\": \"demo\"\n }\n ],\n \"url\": \"lineOfBusinessN\"\n }\n ],\n \"url\": \"https://payer-crd.s3docs.optum.com/StructureDefinition/interqual-line-of-business\"\n }\n ]\n }\n },\n {\n \"name\": \"context\",\n \"valueString\": \"63ec59d6-34de-4766-8884-ffacf706a291\"\n }\n ]\n}"},"Questionnaire Package - Canonical Questionnaire URLs":{"summary":"questionnaire-package: coverage + questionnaire canonical URLs","description":"Requests questionnaire package(s) directly by canonical URL instead of by order.","value":"{\n \"resourceType\": \"Parameters\",\n \"parameter\": [\n {\n \"name\": \"patient\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"PatientExampleId\",\n \"name\": [\n {\n \"family\": \"Doe\",\n \"given\": [\n \"Jane\"\n ]\n }\n ],\n \"gender\": \"female\",\n \"birthDate\": \"1985-10-15\"\n }\n },\n {\n \"name\": \"coverage\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"beneficiary\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"extension\": [\n {\n \"extension\": [\n {\n \"extension\": [\n {\n \"url\": \"key\",\n \"valueString\": \"LineOfBusiness1\"\n },\n {\n \"url\": \"contents\",\n \"valueString\": \"demo\"\n }\n ],\n \"url\": \"lineOfBusinessN\"\n }\n ],\n \"url\": \"https://payer-crd.s3docs.optum.com/StructureDefinition/interqual-line-of-business\"\n }\n ]\n }\n },\n {\n \"name\": \"questionnaire\",\n \"valueCanonical\": \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM24%7CPROCEDURES%7CISP6301%7CR000\"\n },\n {\n \"name\": \"questionnaire\",\n \"valueCanonical\": \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM24%7CPROCEDURES%7CISP7501%7CR000\"\n },\n {\n \"name\": \"context\",\n \"valueString\": \"d3a7fa88-2922-432f-a263-c77604009e02\"\n }\n ]\n}"},"Next Question - Initial Request":{"summary":"next-question: first call for a newly started questionnaire","description":"Starts an adaptive DTR questionnaire session. Submit the QuestionnaireResponse returned by the questionnaire-package stage with status in-progress.","value":"{\n \"resourceType\": \"QuestionnaireResponse\",\n \"id\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse-adapt\"\n ]\n },\n \"contained\": [\n {\n \"resourceType\": \"Questionnaire\",\n \"id\": \"459286\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-adapt\"\n ]\n },\n \"text\": {\n \"status\": \"empty\",\n \"div\": \"

No description available at this time.

\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive\",\n \"valueUrl\": \"https://api.test.auth.optum.com/burden-reduction\"\n }\n ],\n \"identifier\": [\n {\n \"value\": \"RM26|PROCEDURES|ISP6301|R000\"\n }\n ],\n \"name\": \"Adenoidectomy\",\n \"title\": \"Adenoidectomy (CP:Procedures, InterQual® 2026, Mar. 2026 Release)\",\n \"derivedFrom\": [\n \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP6301%7CR000\"\n ],\n \"status\": \"active\",\n \"date\": \"2026-03-20T00:00:00-05:00\"\n }\n ],\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaireresponse-reason\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.ama-assn.org/go/hcpcs\",\n \"code\": \"42831\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"Coverage/\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp\",\n \"code\": \"withpa\",\n \"display\": \"Include in prior authorization\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/94639e43-c830-410a-8309-f2db5343e0b4\"\n }\n }\n ],\n \"identifier\": {\n \"system\": \"https://payer-dtr.s3docs.optum.com/CodeSystem/iqx-consultation-identifier\",\n \"value\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\"\n },\n \"questionnaire\": \"#459286\",\n \"status\": \"in-progress\",\n \"subject\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"authored\": \"2026-10-05T11:19:04.3002+00:00\"\n}"},"Next Question - Request with Answers":{"summary":"next-question: questionnaireResponse with answers","description":"Submits the QuestionnaireResponse populated with answers to get the next question(s), repeating until status is completed.","value":"{\n \"resourceType\": \"QuestionnaireResponse\",\n \"id\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse-adapt\"\n ]\n },\n \"contained\": [\n {\n \"resourceType\": \"Questionnaire\",\n \"id\": \"459286\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-adapt\"\n ]\n },\n \"text\": {\n \"status\": \"empty\",\n \"div\": \"

No description available at this time.

\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive\",\n \"valueUrl\": \"https://api.test.auth.optum.com/burden-reduction\"\n },\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-endpoint\",\n \"valueUri\": \"/caas/fhir/QuestionnaireResponse/$qr-eval\"\n }\n ],\n \"identifier\": [\n {\n \"value\": \"RM26|PROCEDURES|ISP6301|R000\"\n }\n ],\n \"name\": \"Adenoidectomy\",\n \"title\": \"Adenoidectomy (CP:Procedures, InterQual® 2026, Mar. 2026 Release)\",\n \"derivedFrom\": [\n \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP6301%7CR000\"\n ],\n \"status\": \"active\",\n \"date\": \"2026-03-20T00:00:00-05:00\",\n \"description\": \"Informational Note

Adenoidectomy is frequently performed with tonsillectomy. Tonsillectomy must be approved separately. For criteria covering tonsillectomy, see the \\\"Tonsillectomy\\\" criteria subset.    


InterQual® Procedures criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence-based literature and include input from our independent panel of clinical experts. To generate the most appropriate recommendations, a comprehensive literature review of the clinical evidence was conducted. Sources searched included PubMed, Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Reviews, the Cochrane Library, Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations, and the National Institute for Health and Care Excellence (NICE). Other medical literature databases, medical content providers, data sources, regulatory body websites, and specialty society resources may also have been used. Relevant studies were assessed for risk of bias following principles described in the Cochrane Handbook. The resulting evidence was assessed for consistency, directness, precision, effect size, and publication bias. Observational trials were also evaluated for the presence of a dose-response gradient and the likely effect of plausible confounders.

\",\n \"item\": [\n {\n \"id\": \"2042551261\",\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=QUESTION_NOTE&reference=1&questionnaire=459286\"\n }\n ],\n \"linkId\": \"1\",\n \"text\": \"Choose one:\",\n \"type\": \"choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"1\",\n \"display\": \"Age ≥ 18\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"2\",\n \"display\": \"Age < 18\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"1.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n },\n {\n \"id\": \"2042551262\",\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=ANSWER_NOTE&linkId=2&reference=1&questionnaire=459286\"\n },\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=ANSWER_NOTE&linkId=2&reference=2&questionnaire=459286\"\n }\n ],\n \"linkId\": \"2\",\n \"text\": \"Choose one:\",\n \"type\": \"choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"1\",\n \"display\": \"Adenoid tumor by imaging or transnasal endoscopy\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"2\",\n \"display\": \"Obstructive sleep apnea\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"3\",\n \"display\": \"None of the above\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"2.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n },\n {\n \"id\": \"2042551263\",\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=QUESTION_NOTE&reference=9015&questionnaire=459286\"\n }\n ],\n \"linkId\": \"9015\",\n \"text\": \"Obstructive sleep apnea (OSA) confirmed by sleep study or sleep study not tolerated\",\n \"type\": \"choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"Y\",\n \"display\": \"Yes\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"N\",\n \"display\": \"No\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"9015.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n },\n {\n \"id\": \"2042551264\",\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=QUESTION_NOTE&reference=9030&questionnaire=459286\"\n },\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-openLabel\",\n \"valueString\": \"Other clinical information (add comment)\",\n \"_valueString\": {\n \"extension\": [\n {\n \"url\": \"https://integ.ds.interqual.com/caas/fhir/StructureDefinition/additional-context\",\n \"valueCoding\": {\n \"system\": \"urn:interqual:answeroption-code\",\n \"code\": \"3\"\n }\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"key\",\n \"valueId\": \"free-text-exclusive\"\n },\n {\n \"url\": \"human\",\n \"valueString\": \"If any answer is a string, no repetitions are permitted.\"\n },\n {\n \"url\": \"severity\",\n \"valueCode\": \"error\"\n },\n {\n \"url\": \"expression\",\n \"valueExpression\": {\n \"language\": \"text/fhirpath\",\n \"expression\": \"answer.value.ofType(string).exists() implies answer.count() = 1\"\n }\n }\n ],\n \"url\": \"http://hl7.org/fhir/StructureDefinition/targetConstraint\"\n }\n ],\n \"linkId\": \"9030\",\n \"text\": \"Choose one:\",\n \"type\": \"open-choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"1\",\n \"display\": \"Tonsillectomy planned\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"2\",\n \"display\": \"Prior tonsillectomy performed\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"9030.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n },\n {\n \"id\": \"2042551265\",\n \"linkId\": \"9035\",\n \"text\": \"Adenoid hypertrophy confirmed by physical examination or transnasal endoscopy or x-ray\",\n \"type\": \"choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"Y\",\n \"display\": \"Yes\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"N\",\n \"display\": \"No\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"9035.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n }\n ]\n }\n ],\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaireresponse-reason\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.ama-assn.org/go/hcpcs\",\n \"code\": \"42831\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"Coverage/\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp\",\n \"code\": \"withpa\",\n \"display\": \"Include in prior authorization\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/94639e43-c830-410a-8309-f2db5343e0b4\"\n }\n }\n ],\n \"identifier\": {\n \"system\": \"https://payer-dtr.s3docs.optum.com/CodeSystem/iqx-consultation-identifier\",\n \"value\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\"\n },\n \"questionnaire\": \"#459286\",\n \"status\": \"in-progress\",\n \"subject\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"authored\": \"2026-10-05T11:19:04.3002+00:00\",\n \"item\": [\n {\n \"linkId\": \"1\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"1\"\n },\n \"item\": [\n {\n \"linkId\": \"1.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my comment\"\n }\n ]\n }\n ]\n }\n ]\n },\n {\n \"linkId\": \"2\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"2\"\n },\n \"item\": [\n {\n \"linkId\": \"2.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my 2nd comment\"\n }\n ]\n }\n ]\n }\n ]\n },\n {\n \"linkId\": \"9015\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"Y\"\n },\n \"item\": [\n {\n \"linkId\": \"9015.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my 3rd comment\"\n }\n ]\n }\n ]\n }\n ]\n },\n {\n \"linkId\": \"9030\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"2\"\n },\n \"item\": [\n {\n \"linkId\": \"9030.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my 4rd comment\"\n }\n ]\n }\n ]\n }\n ]\n },\n {\n \"linkId\": \"9035\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"Y\"\n },\n \"item\": [\n {\n \"linkId\": \"9035.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my 5th comment\"\n }\n ]\n }\n ]\n }\n ]\n }\n ]\n}"},"Generate Guidance":{"summary":"generate-guidance: two completed QuestionnaireResponses","description":"Submits completed QuestionnaireResponse(s) to produce the final GuidanceResponse documentation determination.","value":"{\n \"resourceType\": \"Parameters\",\n \"parameter\": [\n {\n \"name\": \"questionnaireResponse\",\n \"resource\": {\n \"resourceType\": \"QuestionnaireResponse\",\n \"id\": \"d81b4eab-7780-4047-a853-2fe4cd5ed119\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse-adapt\"\n ]\n },\n \"contained\": [\n {\n \"resourceType\": \"Questionnaire\",\n \"id\": \"432688\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-adapt\"\n ]\n },\n \"text\": {\n \"status\": \"empty\",\n \"div\": \"

No description available at this time.

\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive\",\n \"valueUrl\": \"https://api.test.auth.optum.com/burden-reduction\"\n },\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-endpoint\",\n \"valueUri\": \"/caas/fhir/QuestionnaireResponse/$qr-eval\"\n }\n ],\n \"identifier\": [\n {\n \"value\": \"RM25|PROCEDURES|ISP5302|R000\"\n }\n ],\n \"name\": \"Antireflux Surgery or Hiatal Hernia Repair\",\n \"title\": \"Antireflux Surgery or Hiatal Hernia Repair (CP:Procedures, InterQual® 2025, Mar. 2025 Release)\",\n \"derivedFrom\": [\n \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM25%7CPROCEDURES%7CISP5302%7CR000\"\n ],\n \"status\": \"active\",\n \"date\": \"2025-03-21T00:00:00-05:00\",\n \"description\": \"Informational Note

These criteria include the following procedures: 

Gastroesophageal Reflux Disease (GERD) Surgery

Endoscopic:

Laparoscopic or Open:


Hiatal hernia represents a type of diaphragmatic hernia and is generally classified as either \\\"sliding\\\" or \\\"paraesophageal\\\" but can be \\\"mixed.\\\" Hernias of the diaphragm or those associated with congenital defects or trauma are not covered by these criteria.    


Antireflux surgery usually includes fundoplication, which entails wrapping the fundus of the stomach around the distal esophagus. This tightens the sphincter and creates a higher pressure in the lower esophagus; reflux is thereby minimized. The surgery may be performed as a laparoscopic, endoscopic, or open procedure. Current variations of the procedure range from a total wrap of 360 degrees to partial wraps of 180 degrees or 270 degrees, as well as methods which change the angle of the esophagus.

Laparoscopic fundoplication results in shortened hospital stays, less postoperative complications, and less surgical morbidity than an open procedure (Richter et al., Gastroenterology 2018, 154: 1298-308 e7).


Endoscopic, or endoluminal, treatment for gastroesophageal reflux disease is a surgical alternative developed to tighten the gastroesophageal junction to prevent reflux of gastric contents. Current therapies are classified into 2 basic categories (Sandhu and Fass, Gut Liver 2018, 12: 7-16). :

• Radiofrequency energy delivered to the gastroesophageal tissues aids in tissue constriction and decreases the frequency of transient lower esophageal sphincter relaxations (e.g., Stretta procedure)

• Endoscopic suturing techniques grasp, fold, wrap, and fixate or tighten the tissue around the gastroesophageal junction (e.g., Esophyx, endoscopic plication suturing device)


Limited data are currently available on robotic antireflux surgery. Although surgical outcomes with this technique are similar to Nissen fundoplication, the high cost, significantly prolonged operating time, surgical learning curve, and longer length of hospital stay make it a less attractive surgical option (Rebecchi et al., J Vis Surg 2017, 3: 7; Yates and Oelschlager, Surg Clin North Am 2015, 95: 527-53).


InterQual® Procedures criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence-based literature and include input from our independent panel of clinical experts. To generate the most appropriate recommendations, a comprehensive literature review of the clinical evidence was conducted. Sources searched included PubMed, Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Reviews, the Cochrane Library, Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations, and the National Institute of Health and Care Excellence (NICE). Other medical literature databases, medical content providers, data sources, regulatory body websites, and specialty society resources may also have been used. Relevant studies were assessed for risk of bias following principles described in the Cochrane Handbook. The resulting evidence was assessed for consistency, directness, precision, effect size, and publication bias. Observational trials were also evaluated for the presence of a dose-response gradient and the likely effect of plausible confounders.

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No description available at this time.

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These criteria include the following imaging studies:
3-Dimensional Rendering, Abdomen or Pelvis (3D Reconstruction; 3D Rendering; MR Cholangiopancreatography; MRCP; Multiparametric MRI; mpMRI)
Angiogram, Visceral
Barium Enema (BE)
Barium Swallow (Esophagram, Esophagography, Video Fluoroscopy Swallow Study)
Capsule Endoscopy
Cholecystokinin-Hepatic Iminodiacetic Acid (CCK-HIDA) Scan
Computed Tomography Angiography (CTA), Abdomen
Computed Tomography Angiography (CTA), Abdomen and Pelvis
Computed Tomography (CT), Abdomen
Computed Tomography (CT), Abdomen and Pelvis (CT Urography)
Computed Tomography (CT) Colonography (Virtual Colonoscopy)
Computed Tomography (CT) Enteroclysis
Computed Tomography (CT) Enterography
Computed Tomography (CT), Pelvis
Duplex Scan, Abdomen or Pelvis or Scrotum
Duplex Scan, Abdominal Aorta (AAA)
Esophageal Motility Study
Gastric Emptying Scintigraphy
Gastric Mucosa Imaging
Gastroesophageal Reflux Study
Gastrointestinal (GI) Protein Loss Scintigraphy (Technetium 99m-Labeled HSA Scintigraphy; Dextran Scintigraphy; Indium 111-Labeled Transferrin Scintigraphy)
Hepatobiliary Iminodiacetic Acid (HIDA) Scan
Kidney Scan (Renogram, Renal Scan, DMSA, Lasix, MAG3)
Liver and Spleen Scan, Static Only
Liver and Spleen Scan, Vascular Flow
Liver Scan, Static Only
Liver Scan, Vascular Flow
Magnetic Resonance Angiography (MRA), Abdomen
Magnetic Resonance Angiography (MRA), Abdomen and Pelvis
Magnetic Resonance Imaging (MRI), Abdomen (MRCP; MR Urography)
Magnetic Resonance Imaging (MRI), Pelvis (mpMRI)
Magnetic Resonance (MR) Elastography
Magnetic Resonance (MR) Enteroclysis
Magnetic Resonance (MR) Enterography
Meckel's Scan
Modified Barium Swallow (Videofluoroscopic Swallowing Study (VFSS))
Peritoneal-Venous Shunt Patency Test
Radionuclide Cystogram (RNC)
Radiopharmaceutical Nuclear Scintigraphy, Limited or Multiple Areas, Adrenal (123I-metaiodobenzylguanide scintigraphy; MIBG Scan)
Red Blood Cell Scan (GI Bleeding Scintigraphy; Planar radionuclide RBC scan; Technetium-99m-labeled RBC Scintigraphy; 99mTc RBC scan)
Red Blood Cell Scan with Single-Photon Emission Computed Tomography (SPECT)
Red Blood Cell Scan with Single-Photon Emission Computed Tomography/Computed Tomography (SPECT/CT)
Retrograde Pyelogram
Scrotal Ultrasound (US) with Duplex Ultrasound (US)
Scintigraphy, Adrenal, Cortex or Medulla (Iodocholesterol NP59 Scan)
Scintigraphy, Salivary Flow (Salivagram)
Scrotal Ultrasound (US) with Duplex Ultrasound (US)
Single-Photon Emission Computed Tomography (SPECT), Adrenal (111In-Labeled Pentetreotide Scintigraphy)
Single-Photon Emission Computed Tomography/Computed Tomography (SPECT/CT), Adrenal (Indium 111In-Labeled Pentetreotide Scintigraphy; Octreoscan™)
Small Bowel Follow-Through (SBFT)
Spleen Scan, Vascular Flow
Testicular Scintigraphy with Vascular Flow
Ultrasound (US), Abdominal
Ultrasound (US), Abdominal Aorta
Ultrasound (US), Elastography
Ultrasound (US), Pelvis
Ultrasound (US), Retroperitoneal
Ultrasound (US), Scrotal
Ultrasound (US), Sonohysterogram
Ultrasound (US), Transrectal
Ultrasound (US), Transvaginal
Upper Gastrointestinal (GI) Series
Voiding Cystourethrogram (VCUG)


InterQual® content contains references to patient sex or gender. Depending on the context, these references may refer to either genotype or phenotype. At the individual patient level, a variety of factors, including but not limited to gender identity and gender affirmation via surgery or hormonal treatment, may affect the applicability of some InterQual criteria. This occurs most often with genetic testing and some procedures that require the presence of specific anatomy. For the purpose of these criteria, references to \\\"Male\\\" and \\\"Female\\\" are based on sex assigned at birth, unless otherwise defined. InterQual users should carefully consider patient genotype and anatomy when appropriate.


InterQual® Imaging criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence-based literature and include input from our independent panel of clinical experts. To generate the most appropriate recommendations, a comprehensive literature review of the clinical evidence was conducted. Sources searched included PubMed, Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Reviews, the Cochrane Library, Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations, and the National Institute of Health and Care Excellence (NICE). Other medical literature databases, medical content providers, data sources, regulatory body websites, and specialty society resources may also have been used. Relevant studies were assessed for risk of bias following principles described in the Cochrane Handbook. The resulting evidence was assessed for consistency, directness, precision, effect size, and publication bias. Observational trials were also evaluated for the presence of a dose-response gradient and the likely effect of plausible confounders.

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\"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP7501%7CR000\"\n }\n ]\n}"},"Questionnaire Package - Response":{"summary":"questionnaire-package response","description":"Returns one canonical questionnaire URL per order/topic identified, plus a `processingContextId` for reuse in later `next-question`/`generate-guidance` calls.","value":"{\n \"resourceType\": \"Parameters\",\n \"parameter\": [\n {\n \"name\": \"PackageBundle\",\n \"resource\": {\n \"resourceType\": \"Bundle\",\n \"type\": \"collection\",\n \"entry\": [\n {\n \"fullUrl\": \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP6301%7CR000\",\n \"resource\": {\n \"resourceType\": \"Questionnaire\",\n \"id\": \"459286\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-adapt\"\n ]\n },\n \"text\": {\n \"status\": \"empty\",\n \"div\": \"

No description available at this time.

\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive\",\n \"valueUrl\": \"https://api.test.auth.optum.com/burden-reduction\"\n }\n ],\n \"identifier\": [\n {\n \"value\": \"RM26|PROCEDURES|ISP6301|R000\"\n }\n ],\n \"name\": \"Adenoidectomy\",\n \"title\": \"Adenoidectomy (CP:Procedures, InterQual® 2026, Mar. 2026 Release)\",\n \"derivedFrom\": [\n \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP6301%7CR000\"\n ],\n \"status\": \"active\",\n \"date\": \"2026-03-20T00:00:00-05:00\"\n }\n },\n {\n \"fullUrl\": \"urn:uuid:86f92d8f-e84c-4822-8213-452b720b5cb5\",\n \"resource\": {\n \"resourceType\": \"QuestionnaireResponse\",\n \"id\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse-adapt\"\n ]\n },\n \"contained\": [\n {\n \"resourceType\": \"Questionnaire\",\n \"id\": \"459286\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-adapt\"\n ]\n },\n \"text\": {\n \"status\": \"empty\",\n \"div\": \"

No description available at this time.

\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive\",\n \"valueUrl\": \"https://api.test.auth.optum.com/burden-reduction\"\n }\n ],\n \"identifier\": [\n {\n \"value\": \"RM26|PROCEDURES|ISP6301|R000\"\n }\n ],\n \"name\": \"Adenoidectomy\",\n \"title\": \"Adenoidectomy (CP:Procedures, InterQual® 2026, Mar. 2026 Release)\",\n \"derivedFrom\": [\n \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP6301%7CR000\"\n ],\n \"status\": \"active\",\n \"date\": \"2026-03-20T00:00:00-05:00\"\n }\n ],\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaireresponse-reason\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.ama-assn.org/go/hcpcs\",\n \"code\": \"42831\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"Coverage/\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp\",\n \"code\": \"withpa\",\n \"display\": \"Include in prior authorization\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/94639e43-c830-410a-8309-f2db5343e0b4\"\n }\n }\n ],\n \"identifier\": {\n \"system\": \"https://payer-dtr.s3docs.optum.com/CodeSystem/iqx-consultation-identifier\",\n \"value\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\"\n },\n \"questionnaire\": \"#459286\",\n \"status\": \"in-progress\",\n \"subject\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"authored\": \"2026-10-05T11:19:04.3002+00:00\"\n }\n }\n ]\n }\n },\n {\n \"name\": \"PackageBundle\",\n \"resource\": {\n \"resourceType\": \"Bundle\",\n \"type\": \"collection\",\n \"entry\": [\n {\n \"fullUrl\": \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP7501%7CR000\",\n \"resource\": {\n \"resourceType\": \"Questionnaire\",\n \"id\": \"459343\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-adapt\"\n ]\n },\n \"text\": {\n \"status\": \"empty\",\n \"div\": \"

No description available at this time.

\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive\",\n \"valueUrl\": \"https://api.test.auth.optum.com/burden-reduction\"\n }\n ],\n \"identifier\": [\n {\n \"value\": \"RM26|PROCEDURES|ISP7501|R000\"\n }\n ],\n \"name\": \"Adenoidectomy (Pediatric)\",\n \"title\": \"Adenoidectomy (Pediatric) (CP:Procedures, InterQual® 2026, Mar. 2026 Release)\",\n \"derivedFrom\": [\n \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP7501%7CR000\"\n ],\n \"status\": \"active\",\n \"date\": \"2026-03-20T00:00:00-05:00\"\n }\n },\n {\n \"fullUrl\": \"urn:uuid:f36af125-3243-4e77-9f44-e3d7c2bd56d9\",\n \"resource\": {\n \"resourceType\": \"QuestionnaireResponse\",\n \"id\": \"f36af125-3243-4e77-9f44-e3d7c2bd56d9\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse-adapt\"\n ]\n },\n \"contained\": [\n {\n \"resourceType\": \"Questionnaire\",\n \"id\": \"459343\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-adapt\"\n ]\n },\n \"text\": {\n \"status\": \"empty\",\n \"div\": \"

No description available at this time.

\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive\",\n \"valueUrl\": \"https://api.test.auth.optum.com/burden-reduction\"\n }\n ],\n \"identifier\": [\n {\n \"value\": \"RM26|PROCEDURES|ISP7501|R000\"\n }\n ],\n \"name\": \"Adenoidectomy (Pediatric)\",\n \"title\": \"Adenoidectomy (Pediatric) (CP:Procedures, InterQual® 2026, Mar. 2026 Release)\",\n \"derivedFrom\": [\n \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP7501%7CR000\"\n ],\n \"status\": \"active\",\n \"date\": \"2026-03-20T00:00:00-05:00\"\n }\n ],\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaireresponse-reason\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.ama-assn.org/go/hcpcs\",\n \"code\": \"42831\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"Coverage/\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp\",\n \"code\": \"withpa\",\n \"display\": \"Include in prior authorization\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/94639e43-c830-410a-8309-f2db5343e0b4\"\n }\n }\n ],\n \"identifier\": {\n \"system\": \"https://payer-dtr.s3docs.optum.com/CodeSystem/iqx-consultation-identifier\",\n \"value\": \"f36af125-3243-4e77-9f44-e3d7c2bd56d9\"\n },\n \"questionnaire\": \"#459343\",\n \"status\": \"in-progress\",\n \"subject\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"authored\": \"2026-10-05T11:19:04.3002+00:00\"\n }\n }\n ]\n }\n }\n ]\n}"},"Next Question - Response (Question Returned)":{"summary":"next-question response (status : in-progress)","description":"Illustrative example. Returns the updated `QuestionnaireResponse` with the next question item(s) to present. `status` remains `in-progress`.","value":"{\n \"resourceType\": \"QuestionnaireResponse\",\n \"id\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse-adapt\"\n ]\n },\n \"contained\": [\n {\n \"resourceType\": \"Questionnaire\",\n \"id\": \"459286\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-adapt\"\n ]\n },\n \"text\": {\n \"status\": \"empty\",\n \"div\": \"

No description available at this time.

\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive\",\n \"valueUrl\": \"https://api.test.auth.optum.com/burden-reduction\"\n },\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-endpoint\",\n \"valueUri\": \"/caas/fhir/QuestionnaireResponse/$qr-eval\"\n }\n ],\n \"identifier\": [\n {\n \"value\": \"RM26|PROCEDURES|ISP6301|R000\"\n }\n ],\n \"name\": \"Adenoidectomy\",\n \"title\": \"Adenoidectomy (CP:Procedures, InterQual® 2026, Mar. 2026 Release)\",\n \"derivedFrom\": [\n \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP6301%7CR000\"\n ],\n \"status\": \"active\",\n \"date\": \"2026-03-20T00:00:00-05:00\",\n \"description\": \"Informational Note

Adenoidectomy is frequently performed with tonsillectomy. Tonsillectomy must be approved separately. For criteria covering tonsillectomy, see the \\\"Tonsillectomy\\\" criteria subset.    


InterQual® Procedures criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence-based literature and include input from our independent panel of clinical experts. To generate the most appropriate recommendations, a comprehensive literature review of the clinical evidence was conducted. Sources searched included PubMed, Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Reviews, the Cochrane Library, Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations, and the National Institute for Health and Care Excellence (NICE). Other medical literature databases, medical content providers, data sources, regulatory body websites, and specialty society resources may also have been used. Relevant studies were assessed for risk of bias following principles described in the Cochrane Handbook. The resulting evidence was assessed for consistency, directness, precision, effect size, and publication bias. Observational trials were also evaluated for the presence of a dose-response gradient and the likely effect of plausible confounders.

\",\n \"item\": [\n {\n \"id\": \"2042551261\",\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=QUESTION_NOTE&reference=1&questionnaire=459286\"\n }\n ],\n \"linkId\": \"1\",\n \"text\": \"Choose one:\",\n \"type\": \"choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"1\",\n \"display\": \"Age ≥ 18\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"2\",\n \"display\": \"Age < 18\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"1.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n }\n ]\n }\n ],\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaireresponse-reason\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.ama-assn.org/go/hcpcs\",\n \"code\": \"42831\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"Coverage/\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp\",\n \"code\": \"withpa\",\n \"display\": \"Include in prior authorization\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/94639e43-c830-410a-8309-f2db5343e0b4\"\n }\n }\n ],\n \"identifier\": {\n \"system\": \"https://payer-dtr.s3docs.optum.com/CodeSystem/iqx-consultation-identifier\",\n \"value\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\"\n },\n \"questionnaire\": \"#459286\",\n \"status\": \"in-progress\",\n \"subject\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"authored\": \"2026-10-05T11:19:04.3002+00:00\"\n}"},"Next Question - Response (Completed)":{"summary":"next-question response (status : completed)","description":"Illustrative example. `status` becomes `completed` once all required questions have been answered; the caller should proceed to `generate-guidance`.","value":"{\n \"resourceType\": \"QuestionnaireResponse\",\n \"id\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse-adapt\"\n ]\n },\n \"contained\": [\n {\n \"resourceType\": \"Questionnaire\",\n \"id\": \"459286\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-adapt\"\n ]\n },\n \"text\": {\n \"status\": \"empty\",\n \"div\": \"

No description available at this time.

\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive\",\n \"valueUrl\": \"https://api.test.auth.optum.com/burden-reduction\"\n },\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-endpoint\",\n \"valueUri\": \"/caas/fhir/QuestionnaireResponse/$qr-eval\"\n }\n ],\n \"identifier\": [\n {\n \"value\": \"RM26|PROCEDURES|ISP6301|R000\"\n }\n ],\n \"name\": \"Adenoidectomy\",\n \"title\": \"Adenoidectomy (CP:Procedures, InterQual® 2026, Mar. 2026 Release)\",\n \"derivedFrom\": [\n \"https://integ.ds.interqual.com/caas/fhir/Questionnaire/RM26%7CPROCEDURES%7CISP6301%7CR000\"\n ],\n \"status\": \"active\",\n \"date\": \"2026-03-20T00:00:00-05:00\",\n \"description\": \"Informational Note

Adenoidectomy is frequently performed with tonsillectomy. Tonsillectomy must be approved separately. For criteria covering tonsillectomy, see the \\\"Tonsillectomy\\\" criteria subset.    


InterQual® Procedures criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence-based literature and include input from our independent panel of clinical experts. To generate the most appropriate recommendations, a comprehensive literature review of the clinical evidence was conducted. Sources searched included PubMed, Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Reviews, the Cochrane Library, Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations, and the National Institute for Health and Care Excellence (NICE). Other medical literature databases, medical content providers, data sources, regulatory body websites, and specialty society resources may also have been used. Relevant studies were assessed for risk of bias following principles described in the Cochrane Handbook. The resulting evidence was assessed for consistency, directness, precision, effect size, and publication bias. Observational trials were also evaluated for the presence of a dose-response gradient and the likely effect of plausible confounders.

\",\n \"item\": [\n {\n \"id\": \"2042551261\",\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=QUESTION_NOTE&reference=1&questionnaire=459286\"\n }\n ],\n \"linkId\": \"1\",\n \"text\": \"Choose one:\",\n \"type\": \"choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"1\",\n \"display\": \"Age ≥ 18\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"2\",\n \"display\": \"Age < 18\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"1.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n },\n {\n \"id\": \"2042551262\",\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=ANSWER_NOTE&linkId=2&reference=1&questionnaire=459286\"\n },\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=ANSWER_NOTE&linkId=2&reference=2&questionnaire=459286\"\n }\n ],\n \"linkId\": \"2\",\n \"text\": \"Choose one:\",\n \"type\": \"choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"1\",\n \"display\": \"Adenoid tumor by imaging or transnasal endoscopy\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"2\",\n \"display\": \"Obstructive sleep apnea\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"3\",\n \"display\": \"None of the above\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"2.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n },\n {\n \"id\": \"2042551263\",\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=QUESTION_NOTE&reference=9015&questionnaire=459286\"\n }\n ],\n \"linkId\": \"9015\",\n \"text\": \"Obstructive sleep apnea (OSA) confirmed by sleep study or sleep study not tolerated\",\n \"type\": \"choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"Y\",\n \"display\": \"Yes\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"N\",\n \"display\": \"No\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"9015.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n },\n {\n \"id\": \"2042551264\",\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaire-supportLink\",\n \"valueUri\": \"https://api.test.auth.optum.com/burden-reduction/DocumentReference?queryContext=a64d3785-f82f-4427-a2a1-b2595a1df25d&_query=notes¬eType=QUESTION_NOTE&reference=9030&questionnaire=459286\"\n },\n {\n \"url\": \"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-openLabel\",\n \"valueString\": \"Other clinical information (add comment)\",\n \"_valueString\": {\n \"extension\": [\n {\n \"url\": \"https://integ.ds.interqual.com/caas/fhir/StructureDefinition/additional-context\",\n \"valueCoding\": {\n \"system\": \"urn:interqual:answeroption-code\",\n \"code\": \"3\"\n }\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"key\",\n \"valueId\": \"free-text-exclusive\"\n },\n {\n \"url\": \"human\",\n \"valueString\": \"If any answer is a string, no repetitions are permitted.\"\n },\n {\n \"url\": \"severity\",\n \"valueCode\": \"error\"\n },\n {\n \"url\": \"expression\",\n \"valueExpression\": {\n \"language\": \"text/fhirpath\",\n \"expression\": \"answer.value.ofType(string).exists() implies answer.count() = 1\"\n }\n }\n ],\n \"url\": \"http://hl7.org/fhir/StructureDefinition/targetConstraint\"\n }\n ],\n \"linkId\": \"9030\",\n \"text\": \"Choose one:\",\n \"type\": \"open-choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"1\",\n \"display\": \"Tonsillectomy planned\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"2\",\n \"display\": \"Prior tonsillectomy performed\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"9030.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n },\n {\n \"id\": \"2042551265\",\n \"linkId\": \"9035\",\n \"text\": \"Adenoid hypertrophy confirmed by physical examination or transnasal endoscopy or x-ray\",\n \"type\": \"choice\",\n \"required\": true,\n \"repeats\": false,\n \"answerOption\": [\n {\n \"valueCoding\": {\n \"code\": \"Y\",\n \"display\": \"Yes\"\n }\n },\n {\n \"valueCoding\": {\n \"code\": \"N\",\n \"display\": \"No\"\n }\n }\n ],\n \"item\": [\n {\n \"linkId\": \"9035.comment\",\n \"text\": \"Comment:\",\n \"type\": \"string\",\n \"required\": false,\n \"repeats\": false\n }\n ]\n }\n ]\n }\n ],\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/StructureDefinition/questionnaireresponse-reason\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.ama-assn.org/go/hcpcs\",\n \"code\": \"42831\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"Coverage/\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp\",\n \"code\": \"withpa\",\n \"display\": \"Include in prior authorization\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/94639e43-c830-410a-8309-f2db5343e0b4\"\n }\n }\n ],\n \"identifier\": {\n \"system\": \"https://payer-dtr.s3docs.optum.com/CodeSystem/iqx-consultation-identifier\",\n \"value\": \"86f92d8f-e84c-4822-8213-452b720b5cb5\"\n },\n \"questionnaire\": \"#459286\",\n \"status\": \"completed\",\n \"subject\": {\n \"reference\": \"Patient/PatientExampleId\"\n },\n \"authored\": \"2026-10-05T11:19:04.3002+00:00\",\n \"item\": [\n {\n \"linkId\": \"1\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"1\"\n },\n \"item\": [\n {\n \"linkId\": \"1.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my comment\"\n }\n ]\n }\n ]\n }\n ]\n },\n {\n \"linkId\": \"2\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"2\"\n },\n \"item\": [\n {\n \"linkId\": \"2.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my 2nd comment\"\n }\n ]\n }\n ]\n }\n ]\n },\n {\n \"linkId\": \"9015\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"Y\"\n },\n \"item\": [\n {\n \"linkId\": \"9015.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my 3rd comment\"\n }\n ]\n }\n ]\n }\n ]\n },\n {\n \"linkId\": \"9030\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"2\"\n },\n \"item\": [\n {\n \"linkId\": \"9030.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my 4rd comment\"\n }\n ]\n }\n ]\n }\n ]\n },\n {\n \"linkId\": \"9035\",\n \"answer\": [\n {\n \"valueCoding\": {\n \"code\": \"Y\"\n },\n \"item\": [\n {\n \"linkId\": \"9035.comment\",\n \"answer\": [\n {\n \"valueString\": \"This is my 5th comment\"\n }\n ]\n }\n ]\n }\n ]\n }\n ]\n}"},"Generate Guidance - Response":{"summary":"generate-guidance response","description":"Illustrative example. Represents the final documentation/guidance outcome for the supplied, completed QuestionnaireResponse(s).","value":"{\n \"resourceType\": \"Parameters\",\n \"parameter\": [\n {\n \"name\": \"guidance\",\n \"resource\": {\n \"resourceType\": \"GuidanceResponse\",\n \"contained\": [\n {\n \"resourceType\": \"Parameters\",\n \"id\": \"parameters\",\n \"meta\": {\n \"profile\": [\n \"https://integ.ds.interqual.com/caas/fhir/StructureDefinition/questionnaireresponse-parameters\"\n ]\n },\n \"parameter\": [\n {\n \"name\": \"outcome\",\n \"valueCoding\": {\n \"system\": \"urn:interqual:criteria-status\",\n \"code\": \"notmet\"\n }\n },\n {\n \"name\": \"summary\",\n \"valueString\": \"Evidence supports services as medically necessary.\"\n }\n ]\n }\n ],\n \"requestIdentifier\": {\n \"value\": \"QuestionnaireResponse/d81b4eab-7780-4047-a853-2fe4cd5ed119\"\n },\n \"moduleUri\": \"/InterQual\",\n \"status\": \"success\",\n \"occurrenceDateTime\": \"2026-09-24T02:35:22-05:00\",\n \"outputParameters\": {\n \"reference\": \"#parameters\"\n }\n }\n },\n {\n \"name\": \"guidance\",\n \"resource\": {\n \"resourceType\": \"GuidanceResponse\",\n \"contained\": [\n {\n \"resourceType\": \"Parameters\",\n \"id\": \"parameters\",\n \"meta\": {\n \"profile\": [\n \"https://integ.ds.interqual.com/caas/fhir/StructureDefinition/questionnaireresponse-parameters\"\n ]\n },\n \"parameter\": [\n {\n \"name\": \"outcome\",\n \"valueCoding\": {\n \"system\": \"urn:interqual:criteria-status\",\n \"code\": \"notmet\"\n }\n },\n {\n \"name\": \"summary\",\n \"valueString\": \"Current evidence does not support testing in this clinical scenario\"\n }\n ]\n }\n ],\n \"requestIdentifier\": {\n \"value\": \"QuestionnaireResponse/6ba511e1-8445-481d-b09e-f97282aa46f3\"\n },\n \"moduleUri\": \"/InterQual\",\n \"status\": \"success\",\n \"occurrenceDateTime\": \"2026-09-24T02:35:24-05:00\",\n \"outputParameters\": {\n \"reference\": \"#parameters\"\n }\n }\n }\n ]\n}"}}}},"description":"Successful DTR response"}},"summary":"DTR API Endpoint","tags":["DTR API"]}}},"components":{"securitySchemes":{"bearerAuth":{"type":"http","scheme":"bearer","bearerFormat":"JWT","description":"Bearer token issued by the auth token endpoint. Sent as `Authorization: Bearer `. Note: per the OpenAPI spec, the Authorization header is documented via a security scheme rather than as a plain header parameter."}}}}