Medical Review Criteria Guidelines for Managing Care, 7th edition. 2008  1,225 pages include more than 1,600 clinical ‘benefit interps’/ review criteria clinical guidelines + Length of Stay by DRG tables; extensive authoritative references and resource links. The manual is accompanied by the entire contents on a CD.  This manual is designed for use as a utilization management resource, an educational tool, or a retrospective claims payment review resource. 

This is the most comprehensive clinical review criteria guideline resource available.

Purchasers will receive an updated copy by e-mail on request at any time during the first 8 months after purchase. Support by e-mail is provided for one year following purchase - both services without charge.

¨Introduction:                                                                                                                                                         Introduction to referral authorization management guidelines and criteria; CMS national policies;  Levels of risk in capitation; Basic elements of a utilization management plan; Consultants 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

¨ 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, 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; 

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; 

Dynamic cardiomyoplasty; Extracranial-Intracranial arterial bypass surgery; Heart transplant; Heart volume reduction surgery (partial ventriculectomy); 

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 atrial fibrillation; Pulmonary valve repair and/or replacement; 

Peripheral vascular percutaneous interventional procedures; Cryoplasty; Peripheral vascular rehabilitation; 

Renal Artery Stenosis – Angioplasty, Stent Placement; Robotically-assisted cardiac surgery; Stents; 

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; 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;

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; 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; 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;

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 Ò 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;  Cleft lip/Cleft Palate Repairs; Cochlear Implantation; Cochleostomy with neurovascular transplant; 

Obstructive Sleep Apnea (OSA): Acoustic pharyngometry (Eccovision^TM Acoustic Pharyngometer); SNAP^TM 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;  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; Colonoscopy, Direct & Virtual: screening, diagnostic; Dialysis and related perfusion technology as treatment for hepatic failure; 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;

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; 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; Endoscopic axillary lymph node retrieval; Interstitial laser therapy for fibroadenoma of the breast; Mastectomy; Prophylactic mastectomy; 

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, 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; 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;  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; 

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; Radiofrequency tumor ablation; Radioembolization hepatic malignancies; Therapeutic phlebotomy;  Transcatheter Arterial Chemoembolization; Vaccines to treat various cancers; Cancer-related web sites; Photodynamic Therapy; 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;  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;  

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;  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;

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; 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; 

Multiple Sclerosis (MS) - Therapy, Web Sites; 

Selective peripheral denervation (Bertrand procedure) for spastic torticollis; Spinal tap, diagnostic, Stereotactic Cingulotomy, for severe and intractable pain due to terminal cancer; Sympathetic therapy for chronic pain management; Sympathetic therapy for chronic pain management; Sympathectomy, Thoracoscopic; Transcranial Doppler Ultrasonography; Transient Ischemic Attack (TIA) – Hospitalization Indications; Trigeminal Neuralgia, Cryosurgery; Epiduroscopy; 

Parkinson's Disease/Movement Disorders - Deep brain thalamic stimulation, for the treatment of intractable tremors; Fetal tissue Cell (mesencephalic, adrenal-brain and fetal xenograft) transplantation for the treatment of Parkinson’s disease; L-Dopa therapy;  Pallidotomy for the treatment of Parkinson's disease; Thalamotomy for movement disorders;  

Seizure therapies - Electroencephalographic biofeedback for intractable seizures; Surgical evaluation for intractable seizure disorders - Grid monitoring; Ketogenic diet for the control of intractable seizures in children;  Vagus Nerve Stimulation for the treatment of refractory seizures; 

Carpal Tunnel Syndrome – conservative therapy; Carpal Tunnel Release; 

Embolization of intracranial aneurysms; Electromyelogram (EMG)/Nerve Conduction Velocity (NCV);    

Diabetic Neuropathy: Peripheral neuropathy with loss of protective sensation (LOPS); H-wave stimulation for the management of chronic diabetic peripheral neuropathy;  Decompressive surgery for diabetic neuropathy 

Cognitive Rehabilitation Therapy; Sensory Integration Training; Constraint-induced movement therapy (CIMT); Head injury; Hippotherapy/Therapeutic Horseback Riding/Equestrian Therapy; Hypothermia following acute brain injury; Induced Lesions of Nerve Tracts;   

Intra-operative Electromyographic Monitoring of Cranial Nerves; Invasive Intracranial Pressure Monitoring;  NeuroControl Freehand System; Shunt, subcutaneous lumber; Stroke prevention – Angioplasty of intracerebral arteries; Stroke units; Thalamotomy for movement disorders;

Ulnar Nerve Transposition, Decompression or Release; Vagus Nerve Stimulation for the treatment of depression; Videopupillography/Tropicamide Drop Test for the Diagnosis of Alzheimer's Disease;  Perception Threshold/Sensory Nerve Conduction Threshold (SNCT); Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain; Neurology/Neurosurgery notes.

¨ Nuclear Medicine: 

                                                                                                                                                                                                    Bone scan; CEA scans;  Cardiac Scans – Introduction/Overview, Medicare LMRP; Cardiac scans – thallium and gated pool scans;  Cerebral Scintigraphy for Brain Death; Cholecystokinin Cholescintigraphy/Hepato-biliary scintigraphy; Gastrointestinal scintigraphy; Gated Pool Scan; Liver spleen scan; Monoclonal Antibody (Mab) Imaging/Radioimmunoscintigraphy including Scintimammography; Octreoscans; Parathyroid scintigraphy; 

Positron Emission Tomography (PET scans); PET-CT Fusion Studies; Pulmonary Scintigraphy; Prostate cancer staging scan; Renal Scintigraphy;  Scrotal scintigraphy; Sentinel Lymph Node – Detection, Biopsy; Melanoma/Breast Cancer Staging; 

Scans for Infection and Inflammation; Gallium scans; Indium-III Oxine labeled white blood cells scan; SPECT scans;

Thyroid studies; Tumor Scintigraphy (Gamma Camera); Nuclear medicine notes.

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