Medical Policy and Clinical Guideline Updates
|
|
|
- Christiana Tyler
- 9 years ago
- Views:
Transcription
1 Medical Policy and Clinical Guideline Updates The Medical Policy and Technology Assessment Committee has adopted the following new and/or revised Medical Policies and Clinical Guidelines. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/experimental. All BCBSGa Medical Policies and Clinical Guidelines are available at bcbsga.com (Providers > Choose Medical Policies). Nationally recommended Clinical Practice Guidelines for Attention Deficit/Hyperactivity Disorder (ADHD), Depression, and Substance Use Disorders are available by selecting Provider>Quality Program Information>Clinical Practice Guidelines. Effective Dates are as follows: August 23, 2007: o ADMIN Preventive Health Guideline o CG-TRANS-02 Kidney Transplantation o BEH Treatment of Autism, Asperger s Syndrome, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Development Disorder Not Otherwise Specified (NOS) o New Pharmacology Toolkits September 21, GENE Gene Expression Profiling for Breast Cancer October 15, 2007: All other Medical Policies and Adopted Clinical UM Guidelines If you do not have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical Guideline by calling our Customer Care Center at (800) Monday through Friday from 7 AM to 9 PM or send written requests (specifying the medical policy or guideline of interest, your name and address to where the information should be sent) to: Blue Cross Blue Shield of Georgia Blue Cross Blue Shield Healthcare Plan of Georgia Attention: Prior Approval, Mail Code GAG Peachtree Road NE Atlanta, GA 30326
2 ADMIN Preventive Health Guidelines ANC Biomagnetic Therapy BEH Treatment of Autism, Asperger's Syndrome, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Development Disorder (NOS) DME Electrical Bone Growth Stimulation DME Vacuum Assisted Wound Therapy in the Outpatient Setting DME Continuous Passive Motion Devices DME ibot Mobility System DME Transtympanic Micropressure for the Treatment of Meniere's Disease (including Meniett device) DME Stretching Devices for the Treatment of Joint Stiffness and Contracture DME Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering DME TempTouch Dermal Thermometer DRUG Prostacyclin Infusion Therapy for Treatment of Pulmonary Hypertension (Epoprostenol [Flolan ], Treprostinil [Remodulin ]) DRUG Growth Hormone DRUG Prevention of Respiratory Syncytial Virus Infections DRUG Omalizumab (Xolair ) for Treatment of Asthma DRUG Treatment for Age Related Macular Degeneration DRUG Nebulized Corticosteroids for the Treatment of Nasal Polyps DRUG Histamine Desensitization Therapy DRUG Hormone Replacement Implants DRUG Fluocinolone Acetonide Intravitreal Implant GENE Preimplantation Genetic Diagnosis Testing GENE Gene Expression Profiling for Managing Breast Cancer Treatment LAB Fecal Analysis in the Diagnosis of Intestinal Dysbiosis MED Diagnosis of Sleep Disorders MED Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminesence Microscopy, Videomicroscopy, Ultrasonography) MED Ultraviolet Light, Including Laser Therapy, for the Treatment of Skin Disorders MED Photodynamic Therapy MED Microvolt T-Wave Alternans Testing MED Wireless Esophageal ph Monitoring MED Treatment for Obstructive Sleep Apnea in Adults MED Wearable Cardioverter Defibrillators MED Hepatic Activation Therapy (CIIIT/PIVIT)
3 MED Dry Hydrotherapy (Hydromassage) MED Electrical Stimulation for the Treatment of Facial Palsy MED Carotid Intimal Medial Thickness Measurement MED Nocturnal Enuresis Correction Interventions MED Rhinomanometry and Acoustic Rhinometry MED Treatment of Tinnitus MED Correlated Audioelectric Cardiography MED Fiberoptic Analysis of Colorectal Polyps MED Cutaneous Electrogastrography MED Spinal Manipulation Under Anesthesia MED Cryopreservation of Oocytes or Ovarian Tissue MED Cognitive Rehabilitation MED Melanoma Vaccines MED Intradialytic Parenteral Nutrition and Intraperitoneal Nutrition MED Antineoplaston Therapy RAD Peripheral Bone Mineral Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry RAD Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule RAD Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy) RAD SPECT/CT Fusion Imaging RAD Cerebral Perfusion Imaging using Computed Tomography RAD Cerebral Perfusion Studies using Diffusion and Perfusion Magnetic Resonance Imaging SURG Partial Left Ventriculectomy SURG Implantable Bone Conduction Hearing Aids SURG Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures SURG Surgery for Clinically Severe Obesity SURG Implantable Cardioverter-Defibrillator (ICD) SURG Mandibular/Maxillary (Orthognathic) Surgery SURG Hip Resurfacing SURG Artificial Intervertebral Discs SURG Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure SURG Implantable Infusion Pumps SURG Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) (Including Radiofrequency Ablation of Nasal Turbinates for Nasal Obstruction with or without OSA)
4 SURG Intervertebral Stabilization Devices (Dynesys Spinal System, SATELLITE Spinal System) SURG Nerve Graft After Prostatectomy SURG Laparoscopic and Percutaneous MRI-Image Guided Techniques for Myolysis as a Treatment of Uterine Fibroids SURG Implanted Cerebral Thermal Perfusion Probe for Monitoring Regional Cerebral Blood Flow SURG Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures SURG Semi-Implantable Middle Ear Hearing Aids SURG Mastectomy for Gynecomastia SURG Reduction Mammaplasty SURG Radiofrequency Ablation for Trigeminal Neuralgia SURG Interspinous Vertebral Devices for Treatment of Spinal Stenosis SURG Canaloplasty SURG Cryoablation for Plantar Fasciitis and Plantar Fibroma CG - ANC - 03 Acupuncture CG - DME - 03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy CG - DME - 04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous CG - DME - 05 Cervical Traction Devices for Home Use CG - DME - 06 Pneumatic Compression Devices CG - DME - 07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) CG - DME - 08 Infant Home Apnea Monitors CG - DME - 15 Hospital Beds and Accessories CG - DME - 27 Non-Invasive Positive Pressure Respiratory Assist Devices (BiPAP ) CG - DME - 32 Continuous Positive Airway Pressure (CPAP) and Related Devices for the Treatment of Obstructive Sleep Apnea in Adults CG - DRUG - 03 Beta Interferons (interferon beta-1a [Avonex, Rebif ], interferon beta 1-b [Betaseron ]) or Glatiramer Acetate [Copaxone ] for Treatment of Multiple Sclerosis CG - DRUG - 07 Hepatitis C Pegylated Interferon Antiviral Therapy CG - DRUG - 10 Live Attenuated Influenza Vaccine/FluMist CG - DRUG - 17 Natalizumab (Tysabri ) CG LAB - 01 High Sensitivity C-Reactive Protein CG - MED - 01 Polysomnography Studies in Adults and Children CG - MED - 05 Ketogenic Diet for Intractable Seizure Disorder CG - MED - 06 Intraoperative Neurophysiological Monitoring and Non-Operative Neurophysiological Testing. CG - MED - 07 Upper Gastrointestinal Endoscopy CG - MED - 09 Vision Therapy
5 CG - MED - 10 Measurement of Intermediate Density Lipoproteins CG - MED - 11 Lipoprotein-Associated Phospholipase A2 CG - MED - 12 Lipoprotein Size and Concentration in Cardiac Risk Assessment and Management CG - MED - 13 Cardiopulmonary Exercise Testing CG - MED - 14 Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease and Celiac Disease CG - MED - 16 Amnioreduction and/or Fetoscopic Laser Therapy for Interfetal Transfusion Syndrome CG - MED - 18 Electroencephalography (EEG) Testing: Ambulatory and Video CG - MED - 22 Neuropsychological Testing CG - MED - 23 Home Health CG - MED - 31 Skilled Nursing Facility CG - MED - 34 Anesthesia Services for Gastrointestinal Endoscopic Procedures CG - RAD - 01 Ultrasound Evaluation of Breast Disease CG - RAD - 02 Endoscopic Ultrasonography (EUS) CG - RAD - 04 Ultrasound in Maternity Care CG - RAD - 18 Central (Hip or Spine) Bone Density Measurement CG - REHAB - 03 Pulmonary Rehabilitation CG - REHAB - 04 Physical Therapy CG - REHAB - 05 Occupational Therapy CG - REHAB - 09 Acute Inpatient Rehabilitation CG - SURG - 05 Maze Procedure CG - SURG - 07 Vertical Expandable Prosthetic Titanium Rib (VEPTR) CG - SURG - 08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury CG - SURG - 23 Arthroscopic Lavage and Arthroscopic Debridement as a Treatment for Osteoarthritis of the Knee CG - SURG-24 Functional Endoscopic Sinus Surgery (FESS) CG - TRANS - 02 Kidney Transplantation Toolkit - Abraxane, Paclitaxel Toolkit - Alemtuzumab, Campath Toolkit - Alpha 1 Proteinase Inhibitor Toolkit - Amifostine, Ethyol Toolkit - Arsenic Trioxide, Trisenox Toolkit - Bleomycin Sulfate, Blenoxane, Bleo Toolkit - Busulfan Busulfex, Myleran Toolkit - Carboplatin, Paraplatin, Paraplatin-AQ
6 Toolkit - Carmustine, BiCNU, BCNU, Gliadel Wafer Toolkit - Caspofungin Acetate Toolkit - Cisplatin, Platinol, Platinol-AQ, CDDP, Cisplatinum Toolkit - Cladribine, Leustatin, 2-CdA Toolkit - Cyclophosphamide, Cytoxan, Neosar, CTX Toolkit - Cytarabine, Cytosar-U, ARA-C, cytosine arabinoside, Cytarabine Liposomal (Depo-Cyt ) Toolkit - Cytomegalovirus Immune Globulin (Human) CytoGam Toolkit - Dacarbazine, DTIC Dome, DTIC Toolkit - Dactinomycin, Cosmegen, Actinomycin D Toolkit - Daunorubicin, Cerubidine, DNR, Daunorubicin, Liposomal (DaunoXome ) Toolkit - Denileukin Diftitox, Ontak Toolkit - Docetaxel Toolkit - Dofetilide, Tikosyn Toolkit - Dolasetron, Anzemet Toolkit - Doxorubicin, Adriamycin, Rubex, Doxorubicin Liposomal (Doxil ) Toolkit - Epirubicin Hydrochloride, Ellence Toolkit - Etoposide, VePesis, VP-16 Toolkit - Factor IX, Complex, Recombinant and Non-Recombinant Toolkit - Factor VIIa Toolkit - Factor VIII and Recombinant Toolkit - Floxuridine, FUDR Toolkit - Fludarabine Phosphate, Fludara Toolkit - Flurouracil, Adrucil, 5FU Toolkit - Fulvestrant Toolkit - Galsulfase Toolkit - Gemcitabine, Gemzar Toolkit - Gemtuzumab Ozogamicin, Mylotarg Toolkit - Granisetron, Kytril Toolkit - Ibandronate Toolkit - Idarubicin HCL, Idamycin Toolkit - Idursulfase, Elaprase Toolkit - Ifosfamide, Ifex Toolkit - Immune Globulin Subcutaneous [Human], Vivaglobin
7 Toolkit - Interferon Alfa, Alferon,Intron-A,Roferon-A Toolkit - Interferon Gamma 1-b Toolkit - Irinotecan HCL, Camptosar, CPT-11 Toolkit - Leucovorin, Wellcovorin Toolkit - Mechlorethamine Hydrochloride, Nitrogen mustard, Mustine, Mustargen Toolkit - Medroxyprogesterone, Provera, Depo-Provera Toolkit - Methotrexate, Folex, Mexate, MTX Toolkit - Mitomycin, Mutamycin Toolkit - Mitoxantrone HCL, Novantrone Toolkit - Octreotide Acetate, Sandostatin, Sandostatin LAR Depot Toolkit - Oprelvekin, Neumega, IL-11 Toolkit - Oxaliplatin, Eloxatin Toolkit - Paclitaxel, Taxol Toolkit - Palonosetron Toolkit - Pamidronate Disodium, Aredia Toolkit - Pegasparaginase (Pegaspargase), Oncaspar Toolkit - Pegvisomant Toolkit - Pentostatin, Nipent Toolkit - Rituximab, Rituxan Toolkit - Sotalol (Sotalol HCL), Betapace, Betapace AF Toolkit - Streptozocin, Zanosar Toolkit - Teniposide, Vumon, VM-26 Toolkit - Terbutaline Sulfate, Brethaire, Brethine, Bricanyl Toolkit - Teriparatide Toolkit - Thiotepa, Thioplex Toolkit - Topotecan Toolkit - Trimetrexate glucoronate, Neutrexin Toolkit - Valrubicin, Valstar Toolkit - Vinblastine Sulfate, Velban, Velbe Toolkit - Vincristine Sulfate, Oncovin, Vincasar, VCR Toolkit - Vinorelbine Tartrate, Navelbine Toolkit - Von Willebrand Factor Complex Toolkit - Zoledronate, zoledronic acid, Zometa
8 Milliman Care Guideline - Angioplasty, Percutaneous Coronary Intervention Milliman Care Guideline - Knee Arthroscopy Milliman Care Guideline - Lumbar Fusion W Mastectomy, Modified Radical W Mastectomy, Partial (Lumpectomy) with Axillary Lymphadenectomy W Mastectomy, Modified Radical, with Insertion of Breast Prosthesis or Tissue Expander W Mastectomy, Modified Radical, with Transverse Rectus Abdominis Myocutaneous (TRAM) Flap W Mastectomy, Modified Radical, with Transverse Rectus Abdominis Myocutaneous (TRAM) Flap and Microvascular Anastomosis W Cesarean Section W Vaginal Delivery W Vaginal Delivery, Operative
Hydration, IV Infusions, Injections and Vaccine Charge Process
There are a number of items to be considered when billing for the Nursing service to perform drug therapy, the charge process is divided into three specific groups of codes and processes. 1. Hydration
Preventing and Treating Nausea and Vomiting Caused by Cancer Treatment
A Patient s Guide Preventing and Treating Nausea and Vomiting Caused by Cancer Treatment Recommendations of the American Society of Clinical Oncology The American Society of Clinical Oncology (ASCO) is
Clinical Utilization Management Guidelines
Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government
Oregon CPT Preapproval Grid
* The following grid only identifies items that require preapproval from. Breast Pumps Notes: No preapproval required for 1st month rental; beyond one month rental requires preapproval Genetic Testing
Cost Differences in Cancer Care Across Settings
Cost Differences in Cancer Care Across Settings August 2013 THE MORAN COMPANY 1 Cost Differences in Cancer Care Across Settings In a prior memorandum, we presented evidence documenting the growing share
MEDICAL CENTER ADMINISTRATIVE POLICY AND PROCEDURES SCOPE KFH Hospital, City Section No.
of 22 I. Purpose To establish safe medication practices for High Alert medications to maximize the safety of the medication processes associated with these medications. II. Policy. High alert medications
for Extended Stability Parenteral Drugs Third Edition Caryn M. Bing, R.Ph., M.S., FASHP Editor
Extended Stability for Parenteral Drugs Third Edition Editor Caryn M. Bing, R.Ph., M.S., FASHP 1 American Society of Health-System Pharmacists Bethesda, Maryland Contents Preface Acknowledgments x/ Dedication
Medications most likely to be seen in primary care
Hazardous Medicines The majority of medicines are not classed as hazardous. The only medicinal products that are automatically deemed to be hazardous are cytotoxic and cytostatic medicines. There is no
APPENDIX: CHEMOTHERAPY SIDE EFFECT PROFILES
APPENDIX: CHEMOTHERAPY SIDE EFFECT PROFILES All chemotherapy drugs can cause side effects. No one can predict ahead of time what side effects you may experience or their severity. Some people experience
Prior Authorization Requirements for Florida Effective March 1, 2015
for Florida Effective March 1, 215 General Information The following list represents our prior authorization requirements for UnitedHealthcare in Florida. All services rendered by a non-contracted physician,
Medical Policies and Clinical Utilization Management Guidelines
providers.amerigroup.com Medical Policies and Clinical Utilization Management Guidelines Amerigroup Iowa, Inc. uses nationally recognized, evidence-based Medical Policies and Clinical Utilization Management
Prior Authorization List Adults, FHP, CHP
Please verify the member s benefits before requesting prior authorization (PA). Services vary within plans. To check member eligibility, please call Provider Services at 888-362-3368 or visit UnitedHealthcareOnline.com.
COMPREHENSIVE PRIOR AUTHORIZATION LISTS NJ FAMILYCARE/MEDICAID & DUAL COMPLETE HMO SNP PRODUCTS EFFECTIVE 7/1/13
TO ALL HEALTHCARE PROFESSIONALS: COMPREHENSIVE PRIOR AUTHORIZATION LISTS NJ FAMILYCARE/MEDICAID & DUAL COMPLETE HMO SNP PRODUCTS EFFECTIVE 7/1/13 BEFORE SEEKING PRIOR AUTHORIZATION, PLEASE VERIFY MEMBER
Advance Notification Requirements for New York Effective June 1, 2015
Advance Notification Requirements for New York Effective June 1, 2015 General Information This list represents our prior authorization review requirements for UnitedHealthcare Community Plan of New York.
Medical Policies and Clinical Utilization Management Guidelines
providers.amerigroup.com Medical Policies and Clinical Utilization Management Guidelines Amerigroup* began using Anthem s nationally recognized, evidence-based Medical Policies and Clinical Utilization
MOH Policy for dispensing NEOPLASTIC DISEASES DRUGS
MOH Policy for dispensing NEOPLASTIC DISEASES DRUGS All prescriptions for antineoplastic drugs must be accompanied by the MOH special form. All the attachments mentioned on this form shall be submitted
Enjoy a position of vantage, come what may.
Enjoy a position of vantage, come what may. prucrisis covervantage While you have achieved much in life and you and your family enjoy the benefits of success, there may be times when the unexpected happens.
Medical Surgical Nursing (Elsevier)
1 of 6 I. The Musculoskeletal System Medical Surgical Nursing (Elsevier) 1. Med/Surg: Musculoskeletal System: The Comprehensive Health History 2. Med/Surg: Musculoskeletal System: A Nursing Approach to
(FIDA) FIDELIS CARE AUTHORIZATION REQUIREMENTS
Fully Integrated Duals Advantage (FIDA) FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION 7/1/2016 I. Inpatient Admissions-All inpatient
Filtration Guidelines for the Administration of Intravenous Medications UK Pharmacy Services Revised 8/2010
iltration Guidelines for the Administration of Intravenous Medications UK Pharmacy Services Revised 8/2010 SUMMARY O CHANGES: Green = Added from literature (Lexi-Comp, Micromedex, pkg inserts) Yellow =
UnitedHealthcare Medicare Solutions Notification/Prior Authorization Requirements Effective Jan. 1, 2016
This list represents our advance notification/prior authorization review requirements as referenced in the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider 2016 Administrative
A guide to cancer types and chemotherapy medications
A guide to cancer types and chemotherapy medications This guides lists words that mean cancer, cancer types and intravenous chemotherapy medications. If you have any questions, see page 10 for details
Drugs covered under Medicare Part B or Part D
LABEL_NAME GENERIC_NAME MESSAGE GEMZAR INJ 1 GM GEMCITABINE HCL FOR INJ 1 GM ALIMTA INJ 500MG PEMETREXED DISODIUM FOR IV SOLN 500 MG (BASE EQUIV) FUNGIZONE INJ 50MG AMPHOTERICIN B FOR INJ 50 MG KYTRIL
We understand you want support right from the beginning
PROTECT We understand you want support right from the beginning PRUearly stage crisis cover Should an illness strike, the earlier it is diagnosed, the easier it is to manage and the higher the chances
Synagis (Palivizumab)
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
COVERAGE SCHEDULE. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions:
Exhibit D-3 HMO 1000 Coverage Schedule ROCKY MOUNTAIN HEALTH PLANS GOOD HEALTH HMO $1000 DEDUCTIBLE / 75 PLAN EVIDENCE OF COVERAGE LARGE GROUP Underwritten by Rocky Mountain Health Maintenance Organization,
OGB MAGNOLIA LOCAL COMPREHENSIVE MEDICAL BENEFIT PLAN SCHEDULE OF BENEFITS
OGB MAGNOLIA LOCAL COMPREHENSIVE MEDICAL BENEFIT PLAN SCHEDULE OF BENEFITS Network coverage available only in Baton Rouge, New Orleans, Shreveport and St. Tammany Blue Connect and Community Blue BENEFIT
Disease Modifying Therapies for MS
Disease Modifying Therapies for MS The term disease-modifying therapy (DMT) means a drug that can modify or change the course of a disease. In other words a DMT should be able to reduce the number of attacks
American Maritime Officers Medical Plan Employer Identification Number: 13-5600786 Plan Number: 501 Group Number: 0081717
AMENDMENT #4 American Maritime Officers Medical Plan Employer Identification Number: 13-5600786 Plan Number: 501 Group Number: 0081717 This Amendment is duly adopted and effective as of October 1, 2014.
Cardiac Procedure: Outpatient Office Inpatient Emergent/Urgent Diagnostic Catheterization Required Required Not Not required
Important Changes In Notification and Prior Authorization Procedures (This is revised from the article that was posted in the September 2012 Network Bulletin. Changes are in Section 3, Standardization
New York. UnitedHealthcare Community Plan Claims System Migration Provider Quick Reference Guide. Complete Claims. Our Claims Process
Our Claims Process Here are a few steps to ensure you receive prompt payment: 1 Review and copy both sides of the member s ID card. members receive an ID card containing information that helps you process
2015 Medicare Advantage Summary of Benefits
2015 Medicare Advantage Summary of Benefits HNE Medicare Premium No Rx and HNE Medicare Basic No Rx January 1, 2015 - December 31, 2015 H8578_2015_034 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2015
Spinal Cord Injury Education. An Overview for Patients, Families, and Caregivers
Spinal Cord Injury Education An Overview for Patients, Families, and Caregivers Spinal Cord Anatomy A major component of the Central Nervous System (CNS) It is 15 to 16 inches long, and weighs 1 to 2 ounces
THE HAZARDOUS WASTE (ENGLAND AND WALES) REGULATIONS 2005
THE HAZARDOUS WASTE (ENGLAND AND WALES) REGULATIONS 2005 Interim Guidance for the NHS Hospital Sector for England and Wales and Information for Scotland Additional paper copies may be requested by contacting:
I. Out of Network: There are no OON benefits. However for any medically necessary service not available in network, authorization will be provided
The New York State of Health Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE 7/1/2016 I. Out of Network:
Healthcare services requiring prior authorisation
Annex 2 Healthcare requiring prior authorisation This list does not include organ transplants and does also not apply to long-term care and the primary purpose of which is to support people in need of
University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance
University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview of your benefits.
CRISIS COVER CLAIM FORM (DEAFNESS/ PARTIAL LOSS OF HEARING OR CAVERNOUS SINUS THROMBOSIS SURGERY/ COCHLEAR IMPLANT SURGERY) SECTION
Reg. No 199002477Z CRISIS COVER CLAIM FORM (DEAFNESS/ PARTIAL LOSS OF HEARING OR CAVERNOUS SINUS THROMBOSIS SURGERY/ COCHLEAR IMPLANT SURGERY) SECTION 1 This section is to be completed by the Life Assured
Non-Hodgkin Lymphoma Richard Orlowski, MD
Non-Hodgkin Lymphoma Richard Orlowski, MD The American Cancer Society (ACS) estimates that 69,740 Americans will be diagnosed with non-hodgkin lymphoma (NHL) in 2013. Excluding non-melanoma skin cancers,
Iowa Wellness Plan Benefits Coverage List
Iowa Wellness Plan Benefits Coverage List Service Category Covered Duration, Scope, exclusions, and Limitations Excluded Coding 1. Ambulatory Services Primary Care Illness/injury Physician Services Should
Disease Modifying Therapies for MS
Disease Modifying Therapies for MS The term disease-modifying therapy means a drug that can modify or change the course of a disease. In other words a DMT should be able to reduce the number of attacks
2015 Summary of Benefits
2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3909 Y0041_H3909_PC_15_18889 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how
PHC4 35 Diseases, Procedures, and Medical Conditions for which Laboratory Data is Required Effective 10/1/2015
PHC4 35 Diseases, Procedures, and Medical Conditions for which Laboratory Data is Required Effective 10/1/2015 Laboratory data is to be submitted for discharges in the following conditions: 1. Heart Attack
2015 Summary of Benefits
2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3952 Y0041_H3952_KS_15_18734 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how
January 1, 2015 December 31, 2015
BLUESHIELD FOREVER BLUE MEDICARE PPO VALUE AND BLUESHIELD MEDICARE PPO 750 (PPO) (a Medicare Advantage Preferred Provider Organization (PPO) offered by HEALTHNOW NEW YORK INC. with a Medicare contract)
Summary of Benefits Community Advantage (HMO)
Summary of Benefits Community Advantage (HMO) January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list
PREVENTIVE CARE See the REHP Benefits Handbook for a list of preventive benefits* MATERNITY SERVICES Office visits Covered in full including first
Network Providers Non Network Providers** DEDUCTIBLE (Per Calendar Year) None $250 per person $500 per family OUT-OF-POCKET MAXIMUM (When the out-of-pocket maximum is reached, benefits are paid at 100%
GROUP 1 CARCINOGEN, CHEMOTHERAPY WASTE & OTHER HAZARDOUS DRUG DISPOSAL NAME APPROVAL DATE EFFECTIVE DATE REVISION RENEE MICHEL 05/01/11 0
GROUP 1 CARCINOGEN, CHEMOTHERAPY WASTE & OTHER HAZARDOUS DRUG DISPOSAL NAME APPROVAL DATE EFFECTIVE DATE REVISION RENEE MICHEL 05/01/11 0 INTRODUCTION Prior to commencing work involving carcinogens, chemotherapeutics
BreastCancerTrials.org History Form: Completed Treatment for Breast Cancer ABOUT ME
BreastCancerTrials.org History Form: Completed Treatment for Breast Cancer This form is for patients with DCIS or early stage invasive cancer who are: On hormone therapy after breast cancer surgery Or
Medical Policy Original Effective Date: 11-19-08 Revised Date: 1-27-16 Page 1 of 8
Page 1 of 8 Disclaimer Description Coverage Determination Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans, or the plan
Drugs Used to Treat Nausea and Vomiting
Evaluating the Oral 5-HT3 Antagonists: Drugs Used to Treat Nausea and Vomiting Comparing Effectiveness, Safety, and Price Our Recommendations A Summary The 5-HT3 antagonists are a class of drugs often
Medical Services Protocol Updates
Protocol Medical Services Protocol Updates Distribution Date: June 1, 2010 The following clinical protocol update includes information on protocols that have had an annual review recently resulting in
[2015] SUMMARY OF BENEFITS H1189_2015SB
![[2015] SUMMARY OF BENEFITS H1189_2015SB](/thumbs/32/15705129.jpg "[2015] SUMMARY OF BENEFITS H1189_2015SB")
[2015] SUMMARY OF BENEFITS H1189_2015SB Section I You have choices in your health care One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare
Hawaii Benchmarks Benefits under the Affordable Care Act (ACA)
Hawaii Benchmarks Benefits under the Affordable Care Act (ACA) 10/2012 Coverage for Newborn and Foster Children Coverage Outside the Provider Network Adult Routine Physical Exams Well-Baby and Well-Child
ICD 10 CM IMPLEMENTATION DATE OCT 1, 2015
Presented by: Teri Romano, RN, MBA, CPC, CMDP ICD 10 CM IMPLEMENTATION DATE OCT 1, 2015 Source: http://journal.ahima.org/2015/02/04/us house committee to hold hearing on icd 10 implementation/ 2 2015 Web_Non
Treatment Category Inpatient Treatment Categories DRG (MS DRG) ICD9 [Hip & Knee Only]
![Treatment Category Inpatient Treatment Categories DRG (MS DRG) ICD9 [Hip & Knee Only]](/thumbs/27/9641615.jpg "Treatment Category Inpatient Treatment Categories DRG (MS DRG) ICD9 [Hip & Knee Only]")
NCCT List of Procedures Treatment Category Inpatient Treatment Categories DRG (MS DRG) ICD9 [Hip & Knee Only] Bariatric Surgery - Laparoscopic Gastric Bypass DRG - 288 MS DRG - 621 Cardiac Angioplasty
Preauthorization Requirements * (as of January 1, 2016)
OFFICE VISITS Primary Care Office Visits Primary Care Home Visits Specialist Office Visits No Specialist Home Visits PREVENTIVE CARE Well Child Visits and Immunizations Adult Annual Physical Examinations
Services Requiring Prior Authorization
Anthem Blue Cross of California Medicaid Business Provider Bulletin The table below outlines the services that require Prior Authorization (PA) for Anthem Blue Cross Medicaid Business members enrolled
Services Requiring Prior Authorization
Blue Cross and Blue Shield of Texas Effective September 1, 2015 Services Requiring Prior Authorization The services listed below require authorization prior to providing services to STAR and CHIP Members.
Summary of Benefits. King, Pierce, Snohomish, Spokane and Thurston Counties. premera.com/ma
Summary of Benefits 2016 HMO King, Pierce, Snohomish, Spokane and Thurston Counties premera.com/ma Plus Section 1 Introduction to the and Plus This booklet gives you a summary of what we cover and what
HNE Premier 1 (HMO) and HNE Premier 2 (HMO)
2016 Medicare Advantage Summary of Benefits HNE Premier 1 (HMO) and HNE Premier 2 (HMO) January 1, 2016 - December 31, 2016 H8578_2016_429 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2016 SECTION I
Carcinoma of the vagina is a relatively uncommon disease, affecting only about 2,000 women in
EVERYONE S GUIDE FOR CANCER THERAPY Malin Dollinger, MD, Ernest H. Rosenbaum, MD, Margaret Tempero, MD, and Sean Mulvihill, MD 4 th Edition, 2001 Vagina Jeffrey L. Stern, MD Carcinoma of the vagina is
How To Become A Physio And Rehabilitation Medicine Specialist
EUROPEAN BOARD OF PHYSICAL AND REHABILITATION MEDICINE LOGBOOK EUROPEAN UNION OF MEDICAL SPECIALISTS UEMS IDENTIFICATION... 2 INSTRUCTIONS FOR USE... 3 THE TRAINING COURSE... 3 TRAINING PROGRAMME... 4
January 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1
January, 205 December 3, 205 Summary of Benefits H3928-00 80.06.360.-LA Y0022_205_H3928_00_LA Accepted 9/204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what we
2016 Mayo Clinic Health System Eau Claire Charge and Reimbursement Information for Health Care Consumers Required by 2009 Wisconsin Act 146
2016 Mayo Clinic Health System Eau Claire Charge and Reimbursement Information for Health Care Consumers Required by 2009 Wisconsin Act 146 The Wisconsin Act 146 seeks to make cost and charge information
Understanding How Existing and Emerging MS Therapies Work
Understanding How Existing and Emerging MS Therapies Work This is a promising and hopeful time in the field of multiple sclerosis (MS). Many new and different therapies are nearing the final stages of
FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct PPO Plus (PPO)
FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties 1 P age SECTION I - INTRODUCTION TO SUMMARY
TempCare Health Plan BENEFITS BROCHURE. Short-Term Health Plan for Individuals and Families
TempCare Health Plan BENEFITS BROCHURE Short-Term Health Plan for Individuals and Families Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield Association.
Regence BluePoint 20/40 Plan Highlights For Groups of 51+ 1/1/2015
Plan Features Provider choice: Members have direct access to their choice of providers. Coinsurance levels are lowest for In Network providers. If a member chooses an Out of Network provider, the member
MDC 1 DISEASES AND DISORDERS OF THE NERVOUS SYSTEM Implantation of chemotherapeutic agent Intracranial stents
To assist the readers in identifying all changes that were made to the MS-DRGs as a result of comments, we developed the attached table that summaries those changes. MS-DRG Summary Table PRE-MDC Intestinal
Summary of Benefits January 1, 2016 December 31, 2016. FirstMedicare Direct PPO Plus (PPO)
Summary of Benefits January 1, 2016 December 31, 2016 FIRSTCAROLINACARE INSURANCE COMPANY FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties This booklet
Oncologic drug Exposure Risks and Prevention Guidelines 19 June 2014
Oncologic drug Exposure Risks and Prevention Guidelines 19 June 2014 ส งค กคามซ งอาจเป นอ นตรายต อส ขภาพ HAZARD? HAZARD ส งค กคามซ งอาจเป นอ นตรายต อส ขภาพ ENCLOSURE Substitution ส งค กคามซ งอาจเป นอ นตรายต
GUIDE TO THE PREVENTION OF CHEMOTHERAPY MEDICATION ERRORS
GUIDE TO THE PREVENTION OF CHEMOTHERAPY MEDICATION ERRORS 2nd Edition Sponsored by Please see the approved indication and Important Safety Information (including boxed WARNING) on page 45. Please see the
2015 Summary of Benefits
2015 Summary of Benefits Plans 003 and 004 H6298_14_027 accepted Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list
Guidelines for the Management of. Nausea and Vomiting in Cancer Patients
Guidelines for the Management of Nausea and Vomiting in Cancer Patients Guidelines for the Management of Nausea and Vomiting in Cancer Patients Management of chemotherapy-induced nausea and vomiting includes
Tribute. 2015 Summary of Benefits. Health Plan of Oklahoma. Tribute Health Plan of Oklahoma HMO SNP
Tribute Health Plan of Oklahoma Tribute Health Plan of Oklahoma HMO SNP 2015 Summary of Benefits This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we
January 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H8649-003 80.06.361.1-UTWY A
January, 205 December 3, 205 Summary of Benefits H8649-003 80.06.36.-UTWY A Y0022_205_H8649_003_UT_WYa Accepted /204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient's Name: City: State: Zip Code: Phone: Marital Status: Spouse/Care Giver Name: Phone (H) (W) Occupation:
INPATIENT SERVICES Commercial Medicare. Notification required only, as soon as possible, but no later than 24 hours
Effective: January 1, 2016 Arizona Prior Authorization Requirements HMO (including CommunityCare HMO) Point-of-Service (POS) PPO Advantage (MA) HMO The following services, procedures or equipment are subject
Information About Medicines for Multiple Sclerosis
Information About Medicines for Multiple Sclerosis Information About Medicines for Multiple Sclerosis What is multiple sclerosis? 1 Multiple sclerosis (MS) is a lifelong disease that affects your brain
REFERRALS CPT CODES COMMENTS
Gundersen Health Plan (GHP) Procedures & Services Requiring Prior Authorization Benefits and eligibility must be verified with the Health Plan Customer Service. Self-funded and Fully Insured Employer Group
Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING
Schedule of s HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS ID: MD0000003378_ X Please Note: In this plan, Members have access to network benefits only from the providers in the Harvard Pilgrim-Lahey
MHDO CompareMaine Updated: 9/17/2015
Office Visits -- Adult Preventative Care Office Visit (or Wellness Office Visit) 99385 New patient preventive care visit for adult, ages 18 to 39 99386 New patient preventive care visit for adult, ages
Independent Health s Medicare Passport Advantage (PPO)
Independent Health s Medicare Passport Advantage (PPO) (a Medicare Advantage Preferred Provider Organization Option (PPO) offered by INDEPENDENT HEALTH BENEFITS CORPORATION with a Medicare contract) Summary
ICD-9-CM coding for patients with Spinal Cord Injury*
ICD-9-CM coding for patients with Spinal Cord Injury* indicates intervening codes have been left out of this list. OTHER DISORDERS OF THE CENTRAL NERVOUS SYSTEM (340-349) 344 Other paralytic syndromes
Life Protection Quotation
Life Protection Quotation Prepared For: Date: 03/06/2013 Life Type: Single Life Quote Type: Specified Illness Cover Only QUOTATION DETAILS Male, 43 (01/Jan/1970), Non-Smoker, Specified Illness 124000 Monthly
Integrated Medical Services (IMS) New Patient Registration Sheet
Personal Information Today s Date: Patient First Name: Initial: Last Name: DOB: Age: Social Security #: Email: Address: Street Apt # City/State/Zip Home Phone: Work Phone: Cell phone: Gender : M F Language:
OFFICE OF GROUP BENEFITS 2014 OFFICE OF GROUP BENEFITS CDHP PLAN FOR STATE OF LOUISIANA EMPLOYEES AND RETIREES PLAN AMENDMENT
OFFICE OF GROUP BENEFITS 2014 OFFICE OF GROUP BENEFITS CDHP PLAN FOR STATE OF LOUISIANA EMPLOYEES AND RETIREES PLAN AMENDMENT This Amendment is issued by the Plan Administrator for the Plan documents listed
Course Descriptions: PHTH 533 Functional Anatomy I (5)
Course Descriptions: PHTH 501 Clinical Anatomy/Physiology I (5) This course is the first of three focusing on the structure of the human body and its related function. This course is designed to provide
First Year. PT7040- Clinical Skills and Examination II
First Year Summer PT7010 Anatomical Dissection for Physical Therapists This is a dissection-based, radiographic anatomical study of the spine, lower extremity, and upper extremity as related to physical
Anthem Blue Cross and Blue Shield in Connecticut Precertification Guidelines
Anthem Blue Cross and Blue Shield in Connecticut Precertification Guidelines The following guidelines apply to Anthem Blue Cross and Blue Shield ( Anthem ) products issued and delivered by Anthem in Connecticut.
Low back pain. Quick reference guide. Issue date: May 2009. Early management of persistent non-specific low back pain
Issue date: May 2009 Low back pain Early management of persistent non-specific low back pain Developed by the National Collaborating Centre for Primary Care About this booklet This is a quick reference