Medical Review Criteria Guidelines for Managing Care (8th ed. - 2009)

Medical Review Criteria Guidelines for Managing Care (8th ed. - 2009)

More than 1,600 evidence-based clinical review criteria guidelines listing specific reasonable and necessary indications & criteria for ambulatory care and/or inpatient tests, referrals and procedures.

Comprehensive coverage information. Length of stay benchmarks. Payment criteria. Extensive authoritative references. “The Bible” for health plan and Medicare benefit interpretations. Critical resource for provider education and claims management, as well as traditional UM.

The most comprehensive review criteria guideline resource available.

- INTRODUCTION:

Introduction to evidence-based authorization management guidelines and criteria; CMS national policies; Levels of risk in capitation; Basic elements of a utilization management plan; Consultations vs. referrals; Guidelines; ‘Evaluate and Treat’ orders and authorization requests; Medical Necessity – What is it?; Case law citations related to medical necessity; AHRQ Prevention Quality Indicators; Speed up the review process by …; Hospital Inpatient Admission Criteria, general principles; ‘Automatic’ approval of authorization requests; Medical error coverage; Health and behavior assessments assessment

- ALLERGY:

Allergic rhinitis – Rhinophototherapy, Referral criteria; Allergy referral; Allergy testing and desensitization therapy; Serial Endpoint Allergy Testing; Asthma; Immunotherapy for malignant disease; Leukocyte Histamine Release Test (LHRT);
Food allergies: Food allergy testing and therapy; Challenge testing for food allergies; Screening for Hypersensitivity Reactions to Foods and Chemicals, In Vitro Particle Size Measurement;

Nasal Challenge Test; Omalizumab (Xolair®); Transfer factor; Allergy notes.

- ALTERNATIVE & COMPLEMENTARY MEDICINE (CAM)

Alternative medicine criteria; Acupuncture/Acupressure; Applied Kinesiology; Aromatherapy; Ayurvedic medicine; Biofeedback; Biofeedback for Urinary Incontinence; Magnetic and Bioelectromagnetic Therapy; Diet and Nutrition; Guided imagery; Homeopathy; Hypnotherapy; Manual/massage therapy; Naturopathy; Relaxation therapy; Transcendental meditation; Yoga;
Alternative medicine resources; references; web sites; resource organizations - list; CAM notes.

- ANESTHESIOLOGY/PAIN MEDICINE

Review criteria and payment guidelines: Anesthesia services - General Coverage Policy; Anesthesia for pacemaker implantation; Office-based anesthesia; Bispectral Index Monitor; Dental Anesthesia; Safe sedation of children; Intraoperative Awareness - Monitoring;
Pain Management: Cryoanalgesia; Cold Laser (low-energy or low-level) Therapy for wound healing, pain therapy, and other disorders; Pulsed Radiofrequency for Pain Management;

Nerve blocks: Intrathecal/subarachnoid injections; Epidural injections for pain; Celiac plexus nerve blocks; Continuous epidural analgesia; Facet Joint Injections/Median Branch Nerve Blocks; Intercostal nerve blocks; Paravertebral Nerve Blocks; Percutaneous alcohol injections for the ablation of intractable pain; Transforaminal epidural injections; Anesthesiology Notes.

- BLOOD BANK:

Autologous Blood-Derived Products for Chronic Non-Healing Wounds; Blood transfusions; autologous, allogeneic, donor directed; Cord blood storage; Granulocyte and Platelet Transfusions; Plasmapheresis, Extracorporeal photopheresis for Crohn’s disease; plasma exchange, apheresis and related procedures; Lipid apheresis;
Nonselective (random) transfusions and living-related donor specific transfusions in kidney transplantation; Operative blood salvage; Therapeutic Phlebotomy; Blood bank notes.

- CARDIOLOGY:

Acoustic Heart Scans/Recordings; Ambulatory blood pressure monitoring; Ambulatory electrocardiography (Holter monitor); Arterial elasticity as a screening tool for CV disease; Atrial fibrillation - ablative procedures; Brachytherapy, Coronary; Cardiology consultation or referral; Chest pain - admission criteria, Cardiac catheterization, right heart; Central venous pressure monitoring, Cardiac Catheterization, right heart, Central venous pressure monitoring; Cardiac Catheterization, left heart; Coronary Arteriography; Angiography and Ventriculography;

Ambulatory Cardiac Event Monitors, Holter monitors; Real Time Cardiac Surveillance System – Loop Recorders; Implanted Loop Recorders; Mobile Cardiac Outpatient Telemetry (MCOT); Catheter ablation for atrial fibrillation with HF;

Cardiac Output (CO) Measures, noninvasive; Electrical bioimpedance, thoracic; Inert gas re-breathing techniques; Doppler monitor;
Cardiovascular Nuclear Medicine studies; Congestive Heart Failure – admission, discharge criteria guidelines; CT scans to screen for coronary artery disease; Defibrillator devices: automatic implantable and wearable external cardioverter; Home defibrillators; Direct current cardioversion, elective; Directional coronary atherectomy (DCA); Displacement cardiography/cardiokymography and photokymography;

Echocardiograms, adult and pediatric; Doppler Echocardiography; Stress Echocardiography; Electrocardiograms; Cardiointegram (CIG); EKGs correlated with Acoustic Heart Sounds; Body Surface Potential Mapping; Electrophysiology testing (ET); His bundle studies; Endocardial electrical recording and stimulation (EES), diagnostic;

Enhanced external counterpulsation (ECP) - treatment for severe angina; Exercise Treadmill Test (ETT), routine screening; Exercise Treadmill Test (ETT) - routine, screening; ETT with Thallium imaging; Left ventricular end diastolic pressure (LVEDP) measurement in the outpatient setting.
Pacemakers - permanent cardiac/Resynchronization Therapy; Pacemaker monitors; Pacemakers/External manually activated devices to terminate tachyarrhythmias; Percutaneous Transluminal Coronary Angioplasty (PTCA); Pulmonary Artery Hypertension (PAH) – Iloprost therapy, Prostacyclin infusions; Radiofrequency Catheter Ablation; Stents, coronary artery; Stents, venous; Thoracic electrical bioimpedance; Thrombolysis for acute myocardial infarction; Tilt Table Testing; T-Wave Alternans (TWA) testing; Vascular cryoplasty;

Cardiac Rehabilitation Programs; Phonocardiography and Vectorcardiography; LOS benchmarks/targets for cardiology diagnoses; References re: AMI LOS; Screening for cardiac disease; Cardiology guideline resources, Web links; Referrals; Cardiology notes.

- CARDIOVASCULAR/THORACIC/PERIPHERAL VASCULAR SURGERY:

Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy; Angioplasty Aorta (for aortic stenosis); Aortic Aneurysm Repair – Criteria and Options; Fabric Wrapping of Abdominal Aneurysms; Aortic valve repair and/or replacement; Artifical heart and related; Atherectomy, peripheral; Atrial fibrillation - ablative procedures; Atrial septal defect, repair; Autologous cell therapy for damaged myocardium;

Carotid body tumor resection (Glomectomy); Carotid sinus stimulation; Carotid endarterectomy - Indications, LOS; Carotid/Vertebral Artery Angioplasty and Stenting Procedures; Coronary artery bypass graft(s) surgery (CABG)/Off Pump or Beating Heart CAB - Indications, LOS; Cryoplasty, peripheral arterial

Dynamic cardiomyoplasty; Extracranial-Intracranial arterial bypass surgery; Heart transplant; Heart volume reduction surgery (partial ventriculectomy); Heartsbreath test for cardiac transplant rejection

Impedance plethysmography; Intermittent claudication; Intraoperative Ventricular Mapping; Left Ventricular Assist Devices; Maze Procedure for atrial fibrillation/flutter; Microsurgical lymphaticovenous anastomosis operation for lymphedema; Mitral valve repair and/or replacement;
Patent ductus arteriosus - closure; Patent foramen ovale – closure ; Pectus excavatum and Pectus carinatum - Surgical Correction; Percutaneous radiofrequency ablation for primary and secondary lung cancers; Photophoresis, extracorporeal - Therapy for Heart Transplant Rejection; Post-thoracotomy Pain - Intraoperative, Intercostal Nerves, Cryoanalgesia; Pulmonary vein isolation for a trial fibrillation; Pulmonary valve repair and/or replacement;

Peripheral vascular percutaneous interventional procedures; Cryoplasty; Peripheral vascular rehabilitation; Pseudo aneurysms, Thrombin injection; Pulmonary arterial shunts - balloon angioplasty

Renal Artery Stenosis – Angioplasty, Stent Placement; Robotically-assisted cardiac surgery; Stents; Thoracoscopic aortopexy for tracheomalacia
Thrombectomy, arterial or venous; Total Artificial Heart Replacement; Transcoronary ablation of septal hypertrophy (TASH); Transjugular Intrahepatic Portosystemic Shunt; Transmyocardial laser revascularization; Tricuspid valve repair and/or replacement;
Valvular heart disease - repair and/or replacement guidelines by valve;

Varicose vein/Perforator vein procedures including Endovenous RadiofrequencyAblation Therapy, Sclerotherapy, Endoscopic perforator vein ligation; Venous stents;

Ventricular Assist Devices; Ventricular Reduction/Remodeling or Partial Ventriculectomy; Ventricular Septal Defect (VSD); Vertebral artery surgery; Cardiovascular/Peripheral vascular surgery resource links, notes.

- DERMATOLOGY:

Dermatology referral management; Acne vulgaris treatment, referral criteria - including phototherapy; Actinic keratosis including laser and photodynamic therapy guidelines; Alopecia areata; Atopic dermatitis; Basal cell carcinoma; Biopsy/excision of benign skin and subcutaneous lesions, Cellulitis; Contact dermatitis; Cysts involving the skin and subcutaneous structures;

Decubitus Ulcers, treatment; Dermatoscopy/Digital Epiluminescence Microscopy (DELM)/Skin Surface Microscopy/Total Body Photography; Fungus infections, skin and nails; Dermatophytosis; Grenz Ray Therapy; Herpes Simplex; Herpes Zoster;

Hyperhidrosis therapy; Impetigo and pyoderma; Inflammatory dermatosis/’Rashes’; Hair Loss/Alopecia; Keloids; Laser for actinic lesions;
Malignant melanoma; Isolated limb perfusion for malignant melanoma in an extremity; Melanoma vaccines;

Mohs Micrographic Surgery; Pediculosis (‘lice’); Photochemotherapy for the treatment of scleroderma, extracorporeal; Photodynamic therapy with aminolevulinic acid; Pityriasis rosea;

Psoriasis therapies and referral criteria; PUVA Therapy for Psoriasis; Alefacept Therapy for Psoriasis; Etanercept and Infliximab for Psoriasis in Adults
Rosacea; Scabies; Seborrheic dermatitis/’Dandruff’; Seborrheic keratosis; Squamous cell carcinoma; Tattoos; Verruca Vulgaris/ Warts; Vitiligo; Ultraviolet A Light Therapy; Ultraviolet B Light Therapy; Dermatology notes.

- DISPOSABLE MEDICAL SUPPLIES/DURABLE MEDICAL EQUIPMENT:

Definitions; Medicare Coverage Criteria
Disposable Medical Supplies (DMS)

Incontinence supplies; Porcine Skin and Gradient Pressure Dressings; Ostomy supplies; Surgical dressings; Tracheostomy care supplies; Unna boot; Urological supplies.

Durable Medical Equipment (DME)

Acne treatment heat devices; Anodyne® (near-infrared) therapy for peripheral neuropathy or any condition; ArtAssist® device for severe PAD; Bathroom and Toilet Equipment and Supplies;

Beds/Support Surfaces: Pressure Reducing Support Surfaces, Groups 1, 2, and 3; Air Fluidized Beds; Hospital-type Beds and Bed Accessories/Trapeze Bars; Bed and Pillow Covers for Asthmatics; Bed-wetting Alarm;

Breast Pumps; Catheters, urinary; Chairs, therapeutic; Communication devices/aides; Compression Garments in the Treatment of Venous Stasis Ulcers; Continuous Passive Motion device; Cooling devices, external; Cranial Remodeling Band/Helmet for infants; Diathermy;
Traction: Cervical traction; Lumbar traction; Vertebral decompression therapy; Gravity lumbar reduction chairs;

Diabetes mellitus-related DME - Glucose monitors, blood; Continuous glucose monitoring; GlucoWatch® Biographer – automatic glucose values without a needle-stick; Insulin Syringes; Insulin pens; Jet Injectors for insulin administration; Sleep sentry to detect hypoglycemia;

Electrical Stimulation DME: Dorsal Column Stimulators/Spinal Cord Stimulators: Chronic pain, Angina pectoris; Treatment of Motor Function Disorders with Electric Nerve Stimulation; Functional electrical stimulators; Neuromuscular electrical stimulation (NMES) for disuse atrophy; Neuromuscular or Therapeutic Electrical Stimulation (TES); Transcutaneous electrical nerve stimulation (TENS); ‘Sympathetic Therapy’; Inferential current stimulation; Non-implantable Pelvic Floor Electrical Stimulator; Percutaneous electrical nerve stimulation (PENS); ReliefBand; Implanted Peripheral Electrical Nerve Stimulation; Pulsed electrical stimulation for osteoarthritis of the knee;

Wound care: Autologous blood-derived products for non-healing wounds; Electrical Stimulation for the Treatment of Wounds; Chronic Stage III & IV Musculo-Cutaneous Ulcerations;

Surface electrical muscle stimulation; Bone stimulators: electrical and low-intensity ultrasound; Electrogalvanic Stimulators for Levator Syndrome; H-wave stimulation for the treatment of diabetic neuropathy; Low Frequency Ultrasound Wound Therapy;

Elastic garments, non-covered; Environmental Control Systems; Vaporizers; Exercise Equipment; End diastolic pneumatic compression boot/Circulator boot: for peripheral vascular disease or lymphedema; Hearing aids; Bone-anchored Hearing Aid; Hip protectors; Hospital beds; Infusion pumps; external or implantable; Jobst Burn Garments;
Lifts - seat and patient;

Light Emitting Diode (LED) or Infrared Therapy; Light therapy/phototherapy for seasonal affective disorder; Lymphedema 'Pump'/Manual lymph drainage; Magnetic Pelvic Floor Stimulation (MPFS); Nebulizers; Wound Care; Negative pressure wound therapy (NPWT) Pumps; Radiant Heat Wound Therapy Systems; Neuromuscular electrical stimulation (NMES);

Orthotic/prosthetic devices; Auricular prosthesis; Breast prosthesis, specialized bras for women post-mastectomy; Canes and crutches; Corset Used as Hernia Support; Dynamic Splinting Devices; Facial prostheses; Foot orthotics/therapeutic shoes/Footwear; Hand neuroprosthesis; Hernia Truss/Sykes; Knee braces; Magnetic insoles for plantar heel pain; Magnetic Pelvic Floor Stimulation (MPFS); Myoelectric prosthesis, upper extremity; Arm brace, robotic for post-stroke; Phototherapy for neonatal hyperbilirubinemia; Computerized lower limb prostheses, above-knee; Prosthesis criteria: functional levels; Prosthetic implants; Scoliosis braces; Shoe inserts to relieve back pain in patients with leg length discrepancies; Spinal Orthoses – TLSO, LSO; Spinal Unloading Devices; Splints, Strapping & Casting; TED/Support hose coverage; Prosthetics & orthotics ordered in a hospital or home prior to a skilled nursing facility admission - payment issues

Pulmonary DME: Airway Clearance/High Frequency Chest Wall Oscillation Devices; Carbon dioxide monitors; Heat Treatments - including diathermy and ultrasound for pulmonary conditions; Intrapulmonary Percussive Ventilator (IPV); Mechanical in-exsufflation/in-exsufflator devices; Nebulizers; Oxygen coverage guidelines; Home oxygen; Travel oxygen; Peak expiratory flow meters; Postural drainage boards; Respiratory Assist Devices; Suction pumps; Thairapy ? vest for cystic fibrosis; Thairapy Bronchial Drainage System; Vaporizers

Pneumatic Compression Therapy - End-diastolic for non-healing extremity ulcers; Computerized lower limb prostheses; Prothrombin Time Home Testing Systems; Safety items - coverage;

Speech - Communication DME: Augmentive Communication Aides, Communication boards; Speech aids, electronic;
Standers, Boards and Tables; Therabite Jaw Motion Rehabilitation System; Vacuum therapy as a treatment for female sexual dysfunction; Vitrectomy Face Support; Wigs; Reuse Information Notice.

Mobility: INDEPENDENCE iBOT 4000 Mobility System; Strollers for special needs children; Walkers/Safety rollers; Wheelchairs, Power-type and Power-operated vehicles (POVs);

DMS/DME Miscellaneous Items List - a grid listing 275 additional DME/DMS items with related review recommendations to approve or deny coverage on the basis of medical necessity; DMS/DME notes.

- EDUCATIONAL MATERIALS:

General educational materials, Patient Education Materials Policy - Development, Approval and Review, Institutional and Home Care Patient Education Programs; Medical ‘Self Care’ Educational Programs; Education classes for OB patients; The 'Not Now!' Program; Institutional and Home Care Patient Education Programs; Medicare Coverage of Diabetes Self-management Training; Smoking cessation programs; Education notes.

- EMERGENCY MEDICAL SERVICES:

Emergency services/authorization system, Medicare Emergency Department (ED) Services Coverage Criteria for Claims; Emergency room authorization/claims processing matrix, Emergency treatment criteria; Relationship of ER admissions to insurance status; Ambulance and other medical transportation; EM notes.

- ENT, ORAL SURGERY AND DENTAL SERVICES:

Acoustic neuroma; Ankyloglossia (tongue-tie); Audiological Testing; Auditory Brain Stem Implants; Aural Rehabilitation Therapy; Brain stem auditory evoked response (BER, BAER); Carbogen Inhalation Therapy for the Treatment of Sudden Hearing Loss; Cerumen (ear wax) removal; Cleft lip/Cleft Palate Repairs; Cochlear Implantation; Cochleostomy with neurovascular transplant;

Obstructive Sleep Apnea (OSA): Acoustic pharyngometry (EccovisionTM Acoustic Pharyngometer); SNAPTM Testing System; CPAP for obstructive sleep apnea; Noninvasive Positive Pressure/Bi- PAP; Oral Appliances for Snoring; Palatal implants/Pillar Procedure for OSA; Osteotomy (maxillary, mandibular) for sleep apnea; Uvulopalatopharyngoplasty (UPPP) and palatopharyngoplasty (PPP); Laser Assisted Uvulopharyngoplasty (LAUP); Sleep apnea; Weight reduction surgery for OSA; Referral indications for sleep lab evaluation;

Dental: Dental services; Damage to Sound and Natural Teeth; Dental hospitalization; Dental implants; Oral appliances for the management of migraine headache syndromes, TMJ, OSA; Impacted teeth, extraction; Neuralgia-inducing Cavitational Osteonecrosis - Treatment; Removal of dental amalgams (fillings);
Dynamic Posturography; Electronystagmogram (ENG); Ernest or Eagle’s Syndrome/Stylomandibular Ligament Pain - Treatment with Radiofrequency Thermoneurolysis; Extracorporeal Shock Wave Lithotrypsy (ESWL) for Sialolithiasis (Salivary Stones); Frenulectomy; Impacted teeth – extraction; Intra-operative Electromyographic Monitoring of Cranial Nerves;

Ear: Myringotomy with Tympanostomy Tubes/Laser Myringotomy; Otitis media clinical guideline; Meniett 20 for overpressure treatment of Meniere's Disease; Hearing Tests; Oxygen Inhalation Therapy for Inner Ear Disorders; Electrocochleogram and perilymphatic pressure measurement;
Oral surgery: Oral biopsy for malignancy; Orthodontia; Orthognathic surgery; Application of interdental fixation device for conditions other than fracture or dislocation, includes removal; Mandibular condyle reconstruction with bone and cartilage autograft for hemifacial microsomia;
Mandibular hypomobility rehabilitation; Distraction osteogenesis for craniofacial abnormalities; Nasal endoscopy; Otitis media, recurrent; Otoplasty; Photodynamic therapy for advanced bronchial cancer

Radiofrequency ablation upper respiratory tissue; Rhinomanometry and acoustic rhinometry/Nasal Function Studies; Nasal turbninate procedures; Septoplasty; Septorhinoplasty; Sialendoscopy, therapeutic; Sialorrhea (drooling) - Surgical Treatment;

Sinuplasty; Sinusitis, acute; Sinus endoscopy, with or without computer-augmentation; Smell and Taste – Evaluation;
Streptococcal pharyngitis: Testing and antibiotics for adults at low-risk; Temporomandibular Joint Disorders (TMJ);

Thyroid surgery LOS; Tinnitus: Tinnitus Retraining Therapy; Transcutaneous electrical nerve stimulators (TENS) for severe tinnitus;
Tonsillectomy and/or adenoidectomy; Coblation non-thermal volumetric tissue reduction; Laser tonsillectomy.

Meniere's disease - Transtympanic Gentamicin Injection for treatment of Meniere’s disease; Transtympanic Micropressure Applications/ Meniett 20 as a Treatment of Meniere’s Disease; Ultrasonic Surgery for Meniere’s;

Tracheal intubation; Tympanometry; Tympanostomy tubes; Vertigo; Vestibular Function Testing; Vestibular Rehabilitation; Canalith repositioning;
Laryngoscopy, Diagnostic; Vocal Cord Examination Using Videostroboscopy; Vocal Cord Injections to Prevent Recurrent Aspiration; ENT notes.

- GASTROENTEROLOGY:

Balloon Dilation of Gastrointestinal Tract Strictures; Breath tests for GI disorders; Capsule Imaging Endoscopy/Wireless; Celiac/Coeliac disease/Sprue; Colonoscopy, Direct & Virtual: screening, diagnostic;

Dialysis and related perfusion technology as treatment for hepatic failure; DNA test for colon cancer; Double Balloon Enteroscopy; Dysphagia – Evaluation of swallowing mechanism;

Electrogastrography (EGG); Endoscopy, upper gastrointestinal; Endoscopic Retrograde Cholangiopancreatography (ERCP); Magnetic resonance cholangiopancreatography (MRCP); Endoscopic Ultrasonography; Upper, Lower;

Esophagogastroduodenoscopy (EGD); Esophageal manometry; Esophageal pH monitoring; Injection sclerotherapy for variceal bleeding;
Fecal DNA Testing for Colorectal Cancer Screening and Monitoring; Fecal Occult Blood test, Screening; Fecal Incontinence – Transanal Radiofrequency Treatment; Fiberoptic Analysis of Colonrectal Polyps; Flexible sigmoidoscopy; Gastroesophageal reflux disease (GERD); Gastrophotography; Inflammatory bowel markers; Intestinal Rehabilitation Programs; Implanted Capsule pH Monitoring for GERD; Leukapheresis for inflammatory bowel disease; Motility disorders; Parotid tumors, malignant;

Photodynamic therapy for high grade esophageal dysplasia; Transendoscopic gastroplasty; Stretta and EndoCinch Procedures; Fecal Occult Blood test, screening – positive; Fiberoptic endoscopy for the evaluation of swallowing; Gastric freezing for the treatment of active peptic ulcers; Gastrostomy/PEG tubes; Hepatitis; Hepatitis B; Hepatitis C; Injection Sclerotherapy for bleeding esophageal varices; Gastric Pacing; Liver Biopsy; Liver assist or support devices; Motility Disorders: Upper GI – Diagnosis/Evaluation; Transesophageal Endoscopic Procedures for Gastroesophageal Reflux (GERD); Transjugular Intrahepatic Portosystemic Shunt; Transplantation; Urea breath testing for H. pylori infection; VitaStim for dysphagia;;GI notes.

- GENERAL SURGERY:

Clinical Guidelines for Office-based Surgery; Anal sphincter, artificial; Attempted, aborted or non-completed surgical procedures - payment criteria; Co-surgeon, Assistant Surgeon, and Physician Assistant - payment criteria;

Anal fissure, chronic; Anorectal fistulal repair; Appendectomy; Bariatric surgery; Barrett's esophagus therapy;
Breast surgery (refer to the Plastic Surgery chapter for additional breast surgery guidelines) Breast biopsy; Breast ductal lavage; Breast reconstruction Post-mastectomy; Endoscopic axillary lymph node retrieval; Interstitial laser therapy for fibroadenoma of the breast; Mastectomy; Prophylactic mastectomy;

CMS 'never events' NCDs; Cholecystectomy, open or laparoscopic; Colon resection – Colectomy; Colostomy; Debridement, wound; Esophagectomy; Fecal incontinence - surgical therapy; Gastroesophageal Reflux Device Implantation/Implanted anti-gastroesophageal reflux device; Gastroesophageal Reflux (GERD) Surgery; Gender reassignment surgery; Hemorrhoidectomy – internal and external;

Hepatic resection/ablation for malignancy (Primary or secondary); Microwave ablation for liver metastases;

Hernia repairs: Athletic pubalgia or ‘sports hernias’; Hiatal hernia repair, Incisional hernia repair, Inguinal hernia repair, Tissue replacement for hernia repair; Umbilical hernia repair, Diastasis recti.

Incision and Drainage (I & D) Procedures; Laparoscopy or Peritoneoscopy; Morbid Obesity/Bariatric Surgery, Selection for surgery based on comorbid diabetes and hypertension in addition to BMI;

Wound management: Apligraft ® (Graftskin); Cutaneous Ulcers, Chronic/Wound Care; Debridement, Wound; Non-contact Normothermic Wound Therapy (NNWT); Vacuum-assisted wound closure; (Refer to the DME chapter for additional wound care guidelines)

Pancreatectomy, distal; Pre-operative tests; ‘Second Look’ surgical procedures; Thyroidectomy; Transabdominal artifical bowel sphincter implantation for faecal incontinence; Transanal rectal resection for obstructed defecation syndrome, stapled;

Post-op LOS by procedure, list; Inpatient Days Prior to a Surgical Procedure; Where should a higher-risk procedure be performed in a specific patient or population of patients? General surgery notes.

- HEMATOLOGY/MEDICAL ONCOLOGY:

Hem-Onc Authorization Guideline Notes; Adjuvant Chemotherapy; Adoptive immunotherapy (AIT); Anti-emetic therapy; Antineoplaston therapy; Blood-brain barrier disruption by osmotic agents - coverage; Bone marrow/Stem cell transplant (BMT); Chemotherapy; Umbilical cord blood compatibility testing; Chemoresistance assays/Tumor chemosensitivity; Colorectal cancer therapy; Colon cancer - KRAS Gene Mutation Test; Cryosurgical ablation hepatic lesions; Dendritic cell immunotherapy for cancer; Donor Lymphocyte/Leukocyte Infusions;
Breast Cancer: Overview; Chemotherapy vs Endocrine Therapy for Metastatic Breast Cancer; Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management; Gene expression profiling for breast cancer treatment management; Microwave Thermotherapy for Breast Cancer; Extracorporeal Immunoadsorption; Interstitial laser therapy (ILT) for breast tumors;

Extracorporeal Photopheresis; Extreme Drug Resistance assay; Gene mutation assay for the diagnosis of myeloproliferative disorders; Hematopoietic colony-stimulating factor/Granulocyte-macrophage colony-simulating factor; Hemophilia therapy; Hyperalimentation for patients receiving chemotherapy; Hyperthermia; Hypothermia (regional scalp cooling) – chemotherapy-associated hair loss; Insulin potentiation therapy (IPT); Interleukin-2 (IL-2) Cancer Therapy;

Intrahepatic Chemotherapy for Liver metastasis - Chemoembolization; Intravenous iron; Isolated limb perfusion (ILP); Lung cancer; Mitoxantrone hydrochloride (Novantrone ®); Monoclonal antibodies for cancer therapy; Monoclonal Antibody (Mab) Imaging or Radioimmunoscintigraphy – colorectal cancer staging; Ovarian cancer, advanced; Photodynamic Therapy; Plerixafor Injection (Mozobil); Radiofrequency tumor ablation; Radioembolization hepatic malignancies;

Therapeutic phlebotomy; Transcatheter Arterial Chemoembolization; Vaccines to treat various cancers; Cancer-related web sites; Photodynamic Therapy; Thrombotic thrombocytopenic purpura, assay; Tumor cells, circulating in the blood, test coverage; Vaccines to treat cancer; Vitamin B12 Injections; Hem-Onc notes.

- LABORATORY:


Medicare Coverage of Laboratory Testing; Cancer screening tests; Cardiovascular risk evaluation tests; Celiac disease lab testing; Cholesterol screening tests; Unnecessary tests; Employer-mandated tests and procedures; Diagnostic & screening tests: indications, coverage (HIV, Polymerase chain reaction (PCR) testing, PSA, Thyroid tests); Collagen cross links as markers of bone turnover; Digoxin levels; Hemoglobin A1c or Glycohemoglobin and Glycated Protein Tests; High Sensitivity C-Reactive Protein (hsCRP); Diabetes screening tests - criteria; Microalbuminuria; Antibody Tests for Neurologic Disease; Flow Cytometry;

Genetic Testing: Cytogenetic studies; First-trimester noninvasive screening for chromosomal abnormalities; Genetic/Molecular Susceptibility Screening/Testing/Counseling; Genetic screen for thyroid carcinoma and MEN; Genetic screen for breast and ovarian cancer (BRCA1, 2); Gene Expression Profiling for Managing Breast Cancer Treatment; Genetic testing for cystic fibrosis; Genetic testing for hereditary nonpolyposis colorectal cancer; Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer’s Disease; Genotyping for cytochrome P450 polymorphism;
Hair analysis; Heavy metals and other minerals, test indications; Hemoglobin A1c testing, rapid; Histocompatibility (HLA) testing; Human Chorionic Gonadotropin (hCG) Tests; Human tumor cell assays – Flourescent Cytoprint assay; Extreme drug resistance assay;

Immune cell function assay; Ionic calcium; Iron/Ferritin Studies, Serum; Lipid Profiles/Testing; Lyme Disease Testing; Lymphocyte Mitogen Response Test; Magnesium, serum; Parathyroid hormone testing; Partial Thromboplastin Time (PTT); Prothrombin time tests, home; Screening tests; Tumor markers; Urinalysis for volatile organic compounds; Urine culture, bacterial; Venipuncture, nonroutine; Laboratory References, general; Laboratory notes.

- MISCELLANEOUS:

Assisted Suicide; Autopsies; Body composition measurements; Cryoanalgesia and Cold Laser (low-energy) Therapy for wound healing, pain therapy, and other disorders; Complications following Non-covered Services - Coverage; Death-related Services; Coverage of shipboard and out-of-US medical care;:

Electrosleep Therapy; Experimental/Investigative Services; Histamine desensitization therapy for intractable headache; Hospital Admission Guidelines for Diabetic Adults; Hospital charges for noncovered services; Humanitarian Device Coverage; Hyperbaric Oxygen Therapy;

Immunizations, influenza immunization; Injectable Medications; Laser procedures; Miscellaneous Services – Medicare Basis for Payment Denial; Multiple Chemical Sensitivity Syndrome or Idiopathic Environmental Intolerances (IEI); Organ and Tissue Transplantation - bone marrow, intestinal, solid organs (kidney, liver, intestine, other); Outmoded tests and procedures (table);

Pain rehabilitation programs; Outpatient Hospital Pain Rehabilitation Programs; Pre-operative Hospital Admissions; Inpatient pain rehabilitation; Palliative care guideline links;

Physician's Office within an Institution--Coverage of Services and Supplies Incident to a Physician's Services; ‘Second opinions’; Sleep disorders- testing; Telehealth services; Transportation, medical/Ambulance transports; Notes.

- NEPHROLOGY:

Nephrology Consultation/Referral for ongoing care; Dialysis Therapy For Renal Failure; Peritoneal dialysis catheter insertion; Laboratory tests for CAPD; Arteriovenous fistulae for dialysis; ESRD Hospital Utilization; ESRD coverage issues; Erythropoeitin therapy; Intravenous Iron Therapy;
Acute dialysis; Hemodialysis for the treatment of hepatorenal syndrome; Albumin dialysis for the treatment of acute-on-chronic liver failure; Hemodialysis for the treatment of schizophrenia; Ultrafiltration therapy for heart failure;

Kidney transplantation; Lymphocyte Immune Globulin/Anti-thymocyte Globulin;

L-carnitine supplementation; RenalVysion test; Nephrology web sites; Nephrology notes.

- NEUROLOGY/NEUROSURGERY:


Alzheimer Disease; Aneurysm, intracerebral, screening indications; Antibody tests for neurologic disease; Autogenous epidural blood grafts; Autism and Other Pervasive Developmental Disorders; Sensory Stimulation for Coma; CNS/Brain tumors; Guillain-Barre syndrome (GBS): Therapy;
Intra-epidermal Nerve Fiber Density Measurement; Epidural adhesions; Indications and recommendations for intracranial endovascular neurointerventional procedures - Table; Dystonia, Cervical - Selective Peripheral Denervation; Posterior tibial nerve stimulation; Nystagmus;
Electrical stimulation therapies in neuromuscular disorders: Facial Nerve Paralysis (Bell's Palsy) - Electrotherapy; Cerebral palsy; Spinal Cord Injury; Sacral nerve stimulation for urge incontinence, urinary retention; Stroke; Cranial Electrical Stimulation/Electrosleep Therapy

Neurology Studies: Autonomic Nervous System Function Testing; Brain death, diagnosis; Electroencephalogram (EEG) - standard, ambulatory, sleep-deprived, surgical, video; EEG telephone transmission coverage; Electrocorticography (ECoG); Brain mapping or Quantitive EEG for the diagnosis of psychiatric disorders; Electromyelogram (EMG)/Nerve Conduction Velocity (NCV); Surface EMG; Facial nerve paralysis/Bell's palsy; Neuromuscular junction testing by repetitive stimulation; Stroke and other CNS Disorders; Somatosensory Evoked Responses, Vision Evoked Response test (VER), Vision Evoked Response test (VER); Anal or Urethral Sphincter Electromyography; Sensory Evoked Potentials; Multiple Sleep Latency Test (MSLT); Neuropsychological Testing (NPT);

Headaches; Cervico-occipital headaches – related procedures; Dihydroergotamine (DHE); Histamine desensitization therapies; Neuroimaging for headache - indications