# Example Medical Necessity For Authorization Of Catheters Questionnaire - Common CQL Artifacts for FHIR (US-Based) v2.0.0-ballot

## Questionnaire: Example Medical Necessity For Authorization Of Catheters Questionnaire (Experimental) 

 
This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. 

*  [Tree view](#tabs-tree) 
*  [Sample Rendering](#tabs-sample) 
*  [Form Logic](#tabs-logic) 

#### Contained resources

### Test this Questionnaire

### Responses for this Questionnaire

There are currently no QuestionnaireResponse instances for this Questionnaire defined in this IG.



## Resource Content

```json
{
  "resourceType" : "Questionnaire",
  "id" : "MNACQuestionnaire",
  "contained" : [{
    "resourceType" : "Library",
    "id" : "effective-data-requirements",
    "name" : "EffectiveDataRequirements",
    "status" : "active",
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/library-type",
        "code" : "module-definition"
      }]
    },
    "relatedArtifact" : [{
      "type" : "depends-on",
      "display" : "USCore model information",
      "resource" : "http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived"
    },
    {
      "type" : "depends-on",
      "display" : "FHIR model information",
      "resource" : "http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1"
    }]
  }],
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/cqf-library",
    "valueCanonical" : "http://hl7.org/fhir/us/cql/Library/MNACInitialExpressions"
  },
  {
    "extension" : [{
      "url" : "name",
      "valueCoding" : {
        "system" : "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
        "code" : "patient",
        "display" : "Patient"
      }
    },
    {
      "url" : "type",
      "valueCode" : "Patient"
    },
    {
      "url" : "description",
      "valueString" : "The patient that is to be used to pre-populate the form"
    }],
    "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
  },
  {
    "extension" : [{
      "url" : "name",
      "valueCoding" : {
        "system" : "http://example.org/fhir/CodeSystem/additionalLaunchContext",
        "code" : "ServiceRequest",
        "display" : "ServiceRequest"
      }
    },
    {
      "url" : "type",
      "valueCode" : "ServiceRequest"
    },
    {
      "url" : "description",
      "valueString" : "The ServiceRequest that is to be used to pre-populate the form"
    }],
    "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "cds"
  },
  {
    "url" : "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements",
    "valueCanonical" : "#effective-data-requirements"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "informative",
    "_valueCode" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql"
      }]
    }
  }],
  "url" : "http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire",
  "version" : "2.0.0-ballot",
  "name" : "MNACQuestionnaire",
  "title" : "Example Medical Necessity For Authorization Of Catheters Questionnaire",
  "status" : "active",
  "experimental" : true,
  "date" : "2024-01-17T00:00:00+00:00",
  "publisher" : "HL7 International / Clinical Decision Support",
  "contact" : [{
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/dss"
    }]
  }],
  "description" : "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "US",
      "display" : "United States of America"
    }]
  }],
  "copyright" : "This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf",
  "item" : [{
    "linkId" : "request-info",
    "text" : "Request Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Date of Request"
        }
      }],
      "linkId" : "request-info|date-of-request",
      "text" : "DATE OF REQUEST",
      "type" : "date"
    }]
  },
  {
    "linkId" : "diagnosis-info",
    "text" : "Diagnosis Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Diagnosis"
        }
      }],
      "linkId" : "diagnosis-info|diagnosis",
      "text" : "Diagnosis",
      "type" : "string"
    }]
  },
  {
    "linkId" : "item-requested",
    "text" : "Item Requested",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Item Requested"
        }
      }],
      "linkId" : "item-requested|item",
      "text" : "Item requested",
      "type" : "string"
    }]
  },
  {
    "linkId" : "uti-history",
    "text" : "UTI History",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "UTI in Last Year"
        }
      }],
      "linkId" : "uti-history|uti-last-year",
      "text" : "The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing",
      "type" : "boolean"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Dates of UTIs"
        }
      }],
      "linkId" : "uti-history|uti-dates",
      "text" : "Dates of UTIs in the last year",
      "type" : "string",
      "enableWhen" : [{
        "question" : "uti-history|uti-last-year",
        "operator" : "=",
        "answerBoolean" : true
      }]
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Antibiotics Used"
        }
      }],
      "linkId" : "uti-history|antibiotics-used",
      "text" : "Antibiotics used for UTIs in the last year",
      "type" : "string",
      "enableWhen" : [{
        "question" : "uti-history|uti-last-year",
        "operator" : "=",
        "answerBoolean" : true
      }]
    }]
  },
  {
    "linkId" : "symptoms-info",
    "text" : "Symptoms Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Check Symptoms"
        }
      }],
      "linkId" : "symptoms-info|symptoms",
      "text" : "Check those that apply to your patient",
      "type" : "choice",
      "repeats" : true,
      "answerOption" : [{
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "code" : "Fever",
          "display" : "Fever; state temperature in degree"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "code" : "UrinaryUrgencyFrequency",
          "display" : "Change in urinary urgency, frequency, or incontinence"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "code" : "AutonomicDysreflexia",
          "display" : "Appearance of new or increase in autonomic dysreflexia"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "code" : "PhysicalSignsProstatitis",
          "display" : "Physical signs of prostatitis, epididymitis, orchitis"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "code" : "Immunosuppressed",
          "display" : "The patient is immunosuppressed"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "code" : "Pyuria",
          "display" : "Pyuria"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "code" : "SystemicLeukocytosis",
          "display" : "Systemic leukocytosis"
        }
      }]
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Fever Temperature"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "deg",
          "display" : "deg"
        }
      }],
      "linkId" : "symptoms-info|fever-temperature",
      "text" : "If fever, state temperature in degrees",
      "type" : "decimal",
      "enableWhen" : [{
        "question" : "symptoms-info|symptoms",
        "operator" : "=",
        "answerCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "code" : "Fever"
        }
      }]
    }]
  },
  {
    "linkId" : "catheterization-frequency",
    "text" : "Catheterization Frequency",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Catheterization Frequency"
        }
      }],
      "linkId" : "catheterization-frequency|frequency",
      "text" : "How many times per day does the patient catheterize?",
      "type" : "choice",
      "answerOption" : [{
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
          "code" : "2-4Times",
          "display" : "2-4 times"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
          "code" : "4-6Times",
          "display" : "4-6 times"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
          "code" : "6-8Times",
          "display" : "6-8 times"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
          "code" : "8TimesOrMore",
          "display" : "8 times or more"
        }
      }]
    }]
  },
  {
    "linkId" : "additional-comments",
    "text" : "Additional Comments",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Additional Comment"
        }
      }],
      "linkId" : "additional-comments|comments",
      "text" : "Additional Comment",
      "type" : "string"
    }]
  },
  {
    "linkId" : "physician-info",
    "text" : "Physician Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Physician Name"
        }
      }],
      "linkId" : "physician-info|name",
      "text" : "Physician's Name",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Physician Telephone"
        }
      }],
      "linkId" : "physician-info|mobile",
      "text" : "Telephone",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Physician Fax"
        }
      }],
      "linkId" : "physician-info|fax",
      "text" : "FAX",
      "type" : "string"
    },
    {
      "linkId" : "physician-info|signature",
      "text" : "Physician's Signature",
      "type" : "attachment"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Referring Physician Telephone"
        }
      }],
      "linkId" : "physician-info|phone-referring",
      "text" : "Referring Physician Telephone",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Date"
        }
      }],
      "linkId" : "physician-info|date",
      "text" : "Date",
      "type" : "string"
    }]
  }]
}

```
