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Research And Markets: Study This Medical Review Criteria Guidelines For Managing Care, 4th Edition 2005 Now.

DUBLIN, Ireland -- 949 pages include more than 1,200 clinical 'benefit interps'/ review criteria clinical guidelines. The manual is accompanied by the entire contents on a CD. The manual is designed for use as either a prospective utilization management reference, an educational tool, or for retrospective claims payment review resource.

Research and Markets ( has announced the addition of Medical Review Criteria Guidelines for Managing Care, 4th edition 2005 to their offering

- 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;

- Allergy Testing and Desensitization: Allergy referral, Allergy testing and desensitization therapy; Serial Endpoint Allergy Testing; Immunotherapy for malignant disease; Leukocyte Histamine Release Test (LHRT); Screening for Hypersensitivity Reactions to Foods and Chemicals, In Vitro Particle Size Measurement; Nasal Challenge Test; Rhinitis, allergic - referral criteria; Transfer factor.

- Complementary and Alternative Medicine: Alternative medicine criteria; Acupuncture/Acupressure; 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; Alternative medicine resources; references; web sites; resource organizations;.

- 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; Therapeutic Phlebotomy

- Cardiology: Acoustic Heart Scans/Recordings; Ambulatory blood pressure

monitoring; Ambulatory electrocardiography (Holter monitor); 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; Cardiac Event Monitors; Implanted Loop Recorders; Catheter ablation for atrial fibrillation with HF; Cardiac Output Monitoring by Electrical Bioimpedance ;

Cardiovascular Nuclear Medicine studies; Congestive Heart Failure - admission, discharge criteria guidelines; CT scans to screen for coronary artery disease; Congestive Heart Failure - Hospital admission criteria; Defibrillator devices, automatic implantable cardioverter; Direct current cardioversion, elective; Directional coronary atherectomy (DCA);

Echocardiograms, adult and pediatric; Doppler Echocardiography; Electrocardiograms; Electrophysiology testing (ET); 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; Pacemakers - permanent cardiac/Resynchronization Therapy; Pacemaker monitors; Pacemakers/External manually activated devices to terminate tachyarrhythmias; Percutaneous Transluminal Coronary Angioplasty (PTCA); Radiofrequency Catheter Ablation; Stents, coronary artery; 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.

- Cardiovascular/Peripheral Vascular Surgery: Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy; Aortic Aneurysm Repair - Criteria and Options; Aortic and/or valve replacement; Atherectomy, peripheral; Atrial septal defect, repair; Carotid body tumor resection (Glomectomy); Carotid endarterectomy - Indications, LOS; Carotid/Vertebral Artery Angioplasty and Stenting Procedures; Coronary artery bypass graft(s) surgery (CABG) - Indications, LOS; Extracranial-Intracranial arterial bypass surgery; Heart volume reduction surgery;

Impedance plethysmography; Intermittent claudication; Intraoperative Ventricular Mapping; Left Ventricular Assist Devices; Maze Procedure for atrial fibrillation/flutter; Microsurgical lymphaticovenous anastomosis operation for lymphedema; Pectus excavatum and Pectus carinatum - Surgical Correction; Photophoresis, extracorporeal - Therapy for Heart Transplant Rejection; Post-thoracotomy Pain - Intraoperative, Intercostal Nerves, Cryoanalgesia; Pulmonary vein isolation for atrial fibrillation; Renal Artery Stenosis - Angioplasty, Stent Placement; Transcoronary ablation of septal hypertrophy (TASH); Transjugular Intrahepatic Portosystemic Shunt; Transmyocardial laser revascularization; Varicose vein procedures including Endovenous Ablation Therapy; Ventricular Assist Devices; Ventricular Reduction/Remodeling or Partial Ventriculectomy; Vertebral artery surgery; Peripheral vascular rehabilitation programs.

- Dermatology: Dermatology referral management; Acne vulgaris; Actinic keratosis; Alopecia areata; Atopic dermatitis; Basal cell carcinoma; Biopsy/excision of benign skin and subcutaneous lesions, Cysts involving the skin and subcutaneous structures; Decubitus Ulcers, treatment; Digital Epiluminescence Microscopy (DELM)/Total Body Photography; Fungus infections, skin and nails; Dermatophytosis; Grenz Ray Therapy; Herpes Simplex; Herpes Zoster; Impetigo and pyoderma; Inflammatory dermatosis/'Rashes'; Hair Loss/Alopecia; Keloids;

Laser for actinic lesions; Malignant melanoma; Mohs Micrographic Surgery;

Pediculosis ('lice'); Photochemotherapy for the treatment of scleroderma, extracorporeal; Pityriasis rosea; Psoriasis; PUVA Therapy; Rosacea; Scabies; Sclerotherapy for varicose veins, Seborrheic dermatitis/'Dandruff'; Seborrheic keratosis; Squamous cell carcinoma; Tattoos; Verruca Vulgaris/ Warts; Vitiligo; Ultraviolet A Light Therapy; Ultraviolet B Light Therapy.

- Disposable Medical Supplies/Durable Medical Equipment: Medicare Coverage Criteria for DME; Disposable Medical Supplies (DMS): Incontinence supplies; Urinary Drainage Systems; Porcine Skin and Gradient Pressure Dressings; Ostomy supplies; Unna boot;

Durable Medical Equipment (DME): Definitions; Pressure Reducing Support Surfaces, Groups 1, 2, and 3; Air Fluidized Beds; Bathroom and Toilet Equipment and Supplies; Beds and Bed Accessories/Trapeze Bars; Bed and Pillow Covers for Asthmatics; Bed-wetting Alarm; Breast Pumps; Catheters, urinary; --Cervical traction; Chairs, therapeutic; Communication devices/aides; Compression Garments in the Treatment of Venous Stasis Ulcers; Continuous Passive Motion device; Cranial Remodeling Band/Helmet for infants; Dorsal Column Stimulators - for chronic intractable pain control; Diabetes mellitus-related DME - Glucose monitors, blood; GlucoWatch(R) Biographer - automatic glucose values without a needle-stick; Jet Injectors for insulin administration; Insulin pens; Sleep sentry to detect hypoglycemia; Continuous Glucose Monitoring;

Electrical Stimulation DME include: 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; 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;

Environmental Control Systems; Vaporizers; Exercise Equipment; Hearing aids; Bone-anchored Hearing Aid; Hospital beds, Infusion pumps, external or implantable; Intrapulmonary Percussive Ventilator (IPV); Jobst Burn Garments;

Lifts - seat and patient; Light Emitting Diode (LED) or Infrared Therapy; 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; Corset Used as Hernia Support; Dynamic Splinting Devices; Foot orthotics/therapeutic shoes; Magnetic insoles for plantar heel pain; Myoelectric prosthesis, upper extremity;

Oxygen coverage guidelines; Peak expiratory flow meter; Pneumatic Compression Therapy - End-diastolic for non-healing extremity ulcers; Pressure Reducing Support Surfaces, Group 1 and 2; Computerized lower limb prostheses; Prothrombin Time Home Testing Systems;

Speech aids, electronic; Thairapy O vest for cystic fibrosis; Thairapy Bronchial Drainage System; Therabite Jaw Motion Rehabilitation System; Therapeutic Electrical Stimulation/TES; Transcutaneous Electrical Nerve Stimulation/TENS; Inferential current stimulation; Non-Implantable Pelvic Floor Electrical Stimulator; Implanted Peripheral Electrical Nerve Stimulation; Percutaneous Electrical Nerve Stimulation/PENS; Electrical Stimulation for Chronic Musculo-cutaneous Ulceration; Respiratory Assist Devices; Standers, Boards and Tables; Vitrectomy Face Support; Wheelchairs, Power-type and Power-operated vehicles (POVs); Wigs; DME Screening List - a grid listing 290 additional DME/DMS review guidelines; Reuse Information Notice.

- 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.

- Emergency medical services: Emergency services/authorization system, Emergency room authorization/claims processing matrix, Emergency treatment criteria; Relationship of ER admissions to insurance status; Ambulance and other medical transportation;

- ENT, Oral Surgery and Dental Services: Acoustic neuroma; Audiological Testing; 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; CPAP for obstructive sleep apnea; Noninvasive Positive Pressure/Bi- PAP; Dental services; Dental hospitalization; Damage to Sound and Natural Teeth; Intra-oral appliances for the management of migraine headache syndromes; Dynamic Posturography;

Electronystagmogram (ENG); Ernest or Eagle's Syndrome/Stylomandibular Ligament Pain - Treatment with Radiofrequency Thermoneurolysis; Frenulectomy; Hearing Tests,; Impacted teeth - extraction; Intra-operative Electromyographic Monitoring of Cranial Nerves; Laser assisted Uvulopharyngoplasty (LAUP); Myringotomy with Tympanostomy Tubes/Laser Myringotomy; Meniett 20 for overpressure treatment of Meniere's Disease;

Oral surgery; Oral biopsy for malignancy; Orthodontia; Orthognathic surgery; Distraction osteogenesis for craniofacial abnormalities; Otitis media, recurrent; Otoplasty; Positional vertigo; Rhinomanometry and acoustic rhinometry/Nasal Function Studies; Septoplasty; Septorhinoplasty; Sialorrhea (drooling) - Surgical Treatment; Sinusitis, acute; Sinus endoscopy, with or without computer-augmentation; Smell and Taste - Evaluation coverage;

Temporomandibular Joint Disorders (TMJ); Tinnitus Retraining Therapy; Tonsillectomy and/or adenoidectomy; Transcutaneous electrical stimulators for severe tinnitus; Transtympanic Gentamicin Injection for treatment of Meniere's disease; Tympanometry; Tympanostomy tubes; Ultrasonic Surgery for Meniere's; Uvulopalatopharyngoplasty (UPPP) and palatopharyngoplasty (PPP); Vestibular Function Testing; Vestibular Rehabilitation; Vocal Cord Examination Using Videostroboscopy; Vocal Cord Injections to Prevent Recurrent Aspiration.

- Gastroenterology: Balloon Dilation of Gastrointestinal Tract Strictures; Colonoscopy, Direct & Virtual: screening, diagnostic; Dysphagia - Evaluation of swallowing mechanism; Electrogastrography (EGG); Endoscopic Retrograde Cholangiopancreatography (ERCP); Magnetic resonance cholangiopancreatography (MRCP); Endoscopic Ultrasonography; Upper, Lower; Esophagogastroduodenoscopy (EGD); Flexible sigmoidoscopy; Gastroesophageal reflux disease (GERD); Intestinal Rehabilitation Programs; Implanted Capsule pH Monitoring for GERD;

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; Capsule Imaging Endoscopy/Wireless - Medicare LMRP; 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.

- General Surgery: Clinical Guidelines for Office-based Surgery; Anal fissure, chronic; Appendectomy; Breast surgery - biopsy; Mastectomy; Cholecystectomy, open or laparoscopic; Colon resection - Colectomy, Debridement, Wound; Gastroesophageal Reflux Device Implantation, Gastroesophageal Reflux (GERD) Surgery; Hemorrhoidectomy - internal and external, Hiatal Hernia repair, Incisional Hernia Repair, Inguinal Hernia Repair, Umbilical Hernia Repair, 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;

Non-contact Normothermic Wound Therapy (NNWT); 'Second Look' surgical procedures; Thyroidectomy; 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?

- Hematology/Medical Oncology: Hem-Onc Authorization Guideline Notes; Adjuvant Chemotherapy; Adoptive immunotherapy (AIT); Bone marrow/Stem cell transplant (BMT); Umbilical cord blood compatibility testing; Chemoresistance assays/Tumor chemosensitivity; Chemotherapy vs Endocrine Therapy for Metastatic Breast Cancer; Cryosurgical ablation hepatic lesions; Dendritic cell immunotherapy for cancer; Donor Lymphocyte Infusions; Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management; Extracorporeal Immunoadsorption; Extracorporeal Photopheresis; Hematopoietic colony-stimulating factor/Granulocyte-macrophage colony-simulating factor; Hyperalimentation for patients receiving chemotherapy; Hyperthermia; Hypothermia (regional scalp cooling) - chemotherapy-associated hair loss;

Intrahepatic Chemotherapy for Liver metastasis - Chemoembolization; Isolated limb perfusion (ILP); Mitoxantrone hydrochloride (Novantrone (R)); Monoclonal Antibody (Mab) Imaging or Radioimmunoscintigraphy - colorectal cancer staging; Photodynamic Therapy; Radiofrequency tumor ablation; Therapeutic phlebotomy; Vaccines to treat various cancers; Cancer-related web sites; Photodynamic Therapy; Vaccines to treat various cancers; Vitamin B12 Injections.

- Laboratory: Medicare Coverage of Laboratory Testing; Diagnostic testing, indications, coverage (HIV, PSA, Thyroid examples); Tau, BA-42 and Apolipoprotein E tests for Alzheimer's disease; High Sensitivity C-Reactive Protein (hsCRP); Anti-MAG and Anti-GM1 Antibody Tests for Neurologic Disease; Cytogenetic studies; Human tumor cell assays (Fluorescent Cytoprint assay, Extreme Drug Resistance assay); Genetic/Molecular Susceptibility Screening/Testing; Genetic screen for thyroid carcinoma and MEN; Genetic screen for breast and ovarian cancer (BRCA1, 2); Genetic testing for cystic fibrosis; Genetic testing for hereditary nonpolyposis colorectal cancer; Hair analysis; Heavy metals and other minerals, test indications; Histocompatibility (HLA) testing; Iron/Ferritin Studies, Serum; Tumor markers; Lipid Profiles/Testing; Lyme Disease Testing; Laboratory References, general.

- Miscellaneous: Assisted Suicide; Autopsies; Cryoanalgesia and Cold Laser (low-energy) Therapy for wound healing, pain therapy, and other disorders; Complications following Non-covered Services - Coverage; Hospital Charges for Noncovered Services; Death-related Services; Electrosleep Therapy; Experimental/Investigative Services; Histamine desensitization therapy for intractable headache; Hospital Admission Guidelines for Diabetic Adults;

Hyperbaric Oxygen Therapy; Immunizations; 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; Outmoded tests and procedures; Pain rehabilitation programs; Outpatient Hospital Pain Rehabilitation Programs; Physician's Office within an Institution--Coverage of Services and Supplies Incident to a Physician's Services; 'Second opinions'; Sleep disorders- testing; Transportation, medical/Ambulance transports;

- Nephrology: Nephrology Consultation/Referral for ongoing care; Dialysis Therapy For Renal Failure; Laboratory tests for CAPD; Arteriovenous fistulae for dialysis; ESRD coverage by Medicare vs. Health Plan; Darbepoetin Alfa (Aranesp); Intravenous Iron Therapy; Medicare ESRD Coverage - algorithm; Hemodialysis for the treatment of hepatorenal syndrome; Hemodialysis for the treatment of schizophrenia; L-carnitine supplementation; Nephrology web sites.

- Neurology/Neurosurgical: Autism and Other Pervasive Developmental Disorders; Sensory Stimulation for Coma; Facial Nerve Paralysis (Bell's Palsy) - Electrotherapy; Electroencephalogram (EEG) - standard, ambulatory, sleep-deprived, surgical, video; Electrocorticography (ECoG); Brain mapping or Quantitive EEG for the diagnosis of psychiatric disorders; Electromyelogram (EMG)/Nerve Conduction Velocity (NCV); Spinal Cord Injury Neuropsychological Testing (NPT); Stroke and other CNS Disorders; Somatosensory Evoked Responses, Vision Evoked Response test (VER), Deep Brain electrical Stimulation for intractable tremors; Vision Evoked Response test (VER); Multiple Sclerosis (MS) - Therapy, Web Sites; Multiple Sleep Latency Test (MSLT); Neuropsychological Testing (NPT);

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; Thalamic Electrical Stimulation, for the treatment of intractable tremors; Transcranial Doppler Ultrasonography; Transient Ischemic Attack (TIA) - Hospitalization Indications; Trigeminal Neuralgia, Cryosurgery;

Electroencephalographic biofeedback for intractable seizures; Epiduroscopy; Fetal Tissue Transplantation for the Treatment of Parkinson's disease; Pallidotomy for the treatment of Parkinson's disease; Fetal Tissue Transplantation for the Treatment of Parkinson's disease; Surgical evaluation for intractable seizure disorders - Grid monitoring; Deep Brain electrical Stimulation for intractable tremors; Brain mapping (quantitative EEG) for diagnosis of psychiatric disorders;

Carpal Tunnel Syndrome - conservative therapy; Carpal Tunnel Release; Cranial Electrical Stimulation; Embolization of intracranial aneurysms; Electromyelogram (EMG)/Nerve Conduction Velocity (NCV); Anal or Urethral Sphincter Electromyography; Sensory Evoked Potentials; Ketogenic diet for the control of intractable seizures in children; Peripheral neuropathy with loss of protective sensation (LOPS); H-wave stimulation for the management of chronic diabetic peripheral neuropathy;

Cognitive Rehabilitation Therapy; Constraint-induced movement therapy (CIMT); 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; Ulnar Nerve Transposition, Decompression or Release; Monitoring; Ulnar Nerve Transposition, Decompression or Release; Vagus Nerve Stimulation for the treatment of refractory seizures; 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);

- 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; Indium-III Oxine labeled white blood cells scan; Liver spleen scan; Monoclonal Antibody (Mab) Imaging/Radioimmunoscintigraphy including Scintimammography; Parathyroid scintigraphy;

Positron Emission Tomography (PET scans); Pulmonary Scintigraphy; Prostate cancer staging scan; Renal Scintigraphy; Scrotal scintigraphy; Sentinel Lymph Node

- Detection, Biopsy; Melanoma/Breast Cancer Staging; Scans for Infection and Inflammation; SPECT scans; Thyroid studies; Tumor Scintigraphy (Gamma Camera).

- Nutritional: Nutrition Counseling/Educational Programs; Specialty foods, Liquid nutrition products; Ketogenic diet counseling for refractory seizure control; Low protein food products; Very low fat diets to treat or prevent heart disease; Supplemental Fasting Regimens; Enteral Nutrition/Tube feeding; Parenteral nutrition/Total Parenteral Nutrition (TPN); Internet resources for food and nutrition;

- Obstetrics/Gynecology: Ablation - cervical lesion; Abortion/pregnancy termination

- multiple gestation reduction; Amniocentesis; Cervical cerclage; Cervicography (cervigram); Cesarean section - elective; Chorionic villus sampling; Colposcopy Direct access for OB/GYN services, Dilation and Curettage (D & C), D & C plus hysteroscopy, D & C, Hysteroscopy plus pelvic laparoscopy - same day; Family Planning Services - birth control devices and genetic counseling, Norplant, Oral contraceptives - sterilization - tubal ligation/vasectomy, Sterilization - Tubal ligation or vasectomy, OTC products; Fetal fibronectin testing for preterm labor and delivery risk; Genetic Counseling and Testing; Home births; Hysterectomy; Outpatient hysterectomy; Hysteroscopy/Hysterosonography;

Immunotherapy to decrease the risk of spontaneous abortion; Infertility management: Coverage criteria for females, Coverage criteria for males, Infertility treatment, Artificial insemination, Ova sticks - ovum transfer/uterine lavage - sperm donor/storage/washing; Intracytoplasmic sperm injection; In-Vitro Fertilization (IVF) and Gamete Intra-Fallopian Transfer (GIFT); Multifetal pregnancy reduction (MFPR); Recurrent Pregnancy Loss; Transcervical balloon tubuloplasty; Intra-uterine device (IUD) - removal, Laparoscopy - pelvic; Myomectomy; Nerve Ablation Procedures for Dysmenorrhea, Laparoscopic; Laparoscopic, Oophorectomy;

Papanicolaou tests/'Pap smears' with HPV DNA Testing for Cervical Cancer; Perineorrhaphy, Preimplantation Genetic Diagnosis; Pregnancy; Recurrent pregnancy loss; Presacral neurectomy (PSN) for the treatment of chronic pelvic pain; Salivary estriol test for preterm labor, Salpingectomy/salpingostomy, VABRA aspirator; Ultrasonography in pregnancy, Ultrasonongraphy screen for Down Syndrome, Uterine Activity Monitoring (UAM), Uterine Fibroid (Leiomyomata) Therapy; Uterine artery embolization for the treatment of fibroids; VABRA aspirator; Zinc blood levels in pregnancy.

- Ophthalmology: A-scans, B-scans; Blepharoplasty, ptosis correction and eyelid reconstruction; Capsulotomy; YAG laser; Cataract surgery; Preoperative Evaluation and Testing for Cataract Extraction; Computer-assisted corneal topography; Conjunctivitis; Conjunctivodacryocystorhinostomy; Balloon Dacryocystoplasty/Dacryoplasty for Nasolacrimal Duct Obstruction; Contact Lenses; Corneal graft utilizing amniotic membrane transplantation (AMT); Corneal pachymetry; Corneal post-transplant wound revisions; Corneal wedge resection;

Endothelial cell photography; Entropion; Ectropion; Enucleation; External Ocular Photography; Glaucoma treatment; Optic Nerve Head Topography - Confocal Laser Scanning Tomography, Stereophotogrammetry; Argon Laser Trabeculoplasty; Aqueous drainage/shunt implants for refractory primary open-angle glaucoma; Gold Weight Upper Eye Lid Implants; Grave's Disease Ophthalmopathy; Indocyanine Green Angiography; Intraocular Lens Implant; Iridotomy/Iridectomy; Keratoconus; Keratoplasty; Keratoprosthesis or Artificial Cornea;

Age-related Macular Degeneration (AMD); Macular degeneration: Laser Therapy; Radiation Treatment; Macular Fovea Translocation for AMD; Ocular Photodynamic Therapy (OPT) - Visudyne (Verteporfin) Therapy for Age-related Macular Degeneration; Opthalmoscopy, extended with retinal drawing Orbitotomy; Photocoagulation; Pterygium; Ptosis; Punctal dilation/snipping; Punctal Plugs and Punctoplasty for 'Dry Eyes' Syndrome; Corneal remodeling procedures - Refractive Keratoplasty/Radial Keratotomy/Phototherapeutic Keratectomy; Refractive Keratoplasty/Radial keratotomy; Prosthesis, eye; Eye Examinations - Medicare; Routine vision exam; Scleral buckle; Strabismus correction; Tarsorrhaphy; Transpupillary Thermal Therapy; Viscocanalostomy; Visual Field Testing; Visual training (Orthoptics); Visual Rehabilitation Program; Vitrectomy; Referral criteria summary sheet/grid for common complaints.

- Pediatric: Pediatric authorization guidelines for Lengths of stay; Apnea monitor; Circumcision of the newborn male; Cord blood testing; Cystic fibrosis screening in newborns; Diabetes mellitus - Assessment of Need for Hospitalization for the Stabilization of Newly Diagnosed Children with Diabetes; Diabetes Management Using 'Hepatic Activation' or 'PIVIT' Therapy; Comprehensive pediatric case management services; Early Intervention Programs; Extracorporeal membrane oxygenation (ECMO); Hearing Screening, Newborn; Immunizations, Lead screening - blood - children; Newborn LOS - when infant healthy, Mother requires continued hospital care; Phototherapy; Physician Attendance at Delivery for Evaluation and Management of Newborn; Port Wine Stains.

- Pharmacy: Pharmacy benefits; State of California Knox-Keene act requirements;

Canadian drugs; Formulary; MAC pricing; Generic substitution; Alpha 1-antitrypsin inhibitor therapy; Anticoagulant Therapy - Monitoring; Biologicals; Hepatitis vaccines; Growth hormone replacement (adults and children); Botulinum toxin; Calcitriol; Cancer chemotherapy; Erythropoeitin Therapy; Experimental Drug Therapy; Chelation therapy; Diabetes management therapy/supplies; Diabetic foot ulcers - Regranex gel therapy;

Gonadotropin-releasing hormone therapy; HIV Drug susceptibility and resistance testing; Hyaluronidase, intra-articular injections; Intravenous immunoglobulins (IVIG); IVIG to prevent RSV; Cytomegalovirus Immune Globulin Intravenous, Human (CMV-IVIG); Interferon therapy; Intrathecal Baclofen for spasticity; Intravenous Histamine Therapy; Iontophoresis - applications in transdermal medication delivery;

Low molecular weight heparin; Lyme disease vaccine; Meningococcal vaccine; Mifepristone (Mifeprex(TM), RU 486); Nicotine patch, gum or nasal spray therapy for smoking cessation; Off-label drug therapy; Oral contraceptives; Phonophoresis; Prior authorization list w/indications; Platelet-derived Growth Factor for Wound Healing (Regranex, Procuren); Prophylactic antibiotics; Prostacyclin infusion therapy; Sexual function therapy; Smallpox Vaccination; Topical steroids; Transfer Factor; Tumor Necrosis Factor Inhibitors - Ankylosing Spondylitis, Ulcerative Colitis, Psoriasis; Injectable drugs; Pharmacy web sites.

- Plastic Surgery: Abdominoplasty/Panniculectomy Breast surgery - Implant removal and/or replacement; Gynecomastia reconstruction in the male patient; Augmentation mammoplasty; Reduction mammoplasty or breast reduction surgery; Liposuction: Lipectomy, Suction-assisted; Cosmetic surgery; Chemical exfoliation or peel; Cosmetic laser surgery; Cutaneous Ulcer, Chronic - Electrical Stimulation; Ear lobe deformities; Hair transplantation; Mentoplasty (Chin Augmentation, Genioplasty); Plastic Surgery to Correct "Moon Face"; Porcine Skin and Gradient Pressure Dressings; Reconstructive surgery - general criteria; Scar revisions; Skin redundancy following massive weight loss.

- Pulmonary: Pulmonary function tests; Quantitative pilocarpine iontophoresis sweat test; Duration IV antibiotics for pneumonia; Electrophrenic Pacemaker; Fiberoptic bronchoscopy; Lung volume reduction surgery; Sleep apnea studies/Polysomnography; Sleep apnea studies, portable; BiPap; Phrenic nerve pacing/Diaphragm pacing; Positive Expiratory Pressure (PEP) for Cystic Fibrosis Therapy; Noninvasive Positive-Pressure Ventilation (NPPV) for COPD; Postural Drainage Procedures and Pulmonary Exercises; Pulmonary Rehabilitation; Outpatient Pulmonary Rehabilitation (PR); COPD guideline resources and links; 'Virtual' Lung Scans.

- Radiology: Documentation requirements; Imaging guidance during surgical procedures; Bone Mass Measurement/Bone mineral density (BMD) testing; Skeletal surveys in children; Cardiac scans for CAD; Cerebral angiography; Chest x-rays, routine; Contrast media; Spine - diagnostic radiology in adults and children; Imaging studies in acute low back pain; Myelography and Cisternography; Discography; Scoliosis in children - indications for radiography; Epidurogram/Epiduroscopy;

Breast imaging studies: Diaphanography of the breast; Mammography, screening or diagnostic/Digital/CAD mammography; Magnetic Resonance Imaging of the Breast: Differential Diagnosis; Breast Ultrasound and Echography; Stereotactic Breast Biopsy;

Diagnostic radiology - general; Extremity x-rays; Knee trauma; Diagnostic Arteriography - Indications; Cervicocerebral angiography; Digital subtraction angiography (DSA); Infusion Venography; Resources for Angiography Indications; Abdominal and Gastroenterological X-ray Procedures; Cholescintigraphy (HIDA); Cinedefecography; Herniography; Urological: Intravenous Pyelography (IVP); Cystography and Urethrography; Voiding cystourethrography in Children;

MRI and CT scans - Computerized Tomography (CT) or Computerized Axial Tomography (CAT) - Overview; Computerized Tomography (CT or CAT) including extracranial head, brain and thoracic scans; High-resolution CT (HRCT) for Pulmonary Studies; CT for appendicitis; Spiral CT Scans for Lung Cancer Screening; Helical CT for Pulmonary Embolism Detection; Computerized Axial Tomography (CT) Scans: Pelvis, Abdomen, Abdomen and Pelvis - on the same day; Electron-beam CT screening for coronary artery disease; Ultrasound of peripheral sites (tibia, phalanges) for the selection of patients for pharmacologic treatment of osteoporosis;

MRI Studies - Overview; 'Standing' and 'Sitting' MRI Scans; MRI Brain; MRI Orbit, Face, and Neck; MRI Spine; MRI/MRA - Cardiovascular studies; MRI Abdomen and Pelvis; Tumor staging; Table citing optimal imaging studies by region; CT Angiogram; MRI and CT-guided biopsies; Magnetic Resonance Angiography (MRA) including Venography; Magnetic resonance spectroscopy/Nuclear magnetic resonance; Magnetic Source Imaging (MSI)/Magnetoencephalography (MEG);

Neuroimaging Studies for Headaches; Metastatic bone disease - radiologic evaluation; Percutaneous Drainage/Aspiration of Abscesses and Fluid Collection; Percutaneous Permanent Inferior Vena Cava Placement; Percutaneous Transcatheter Embolization; Percutaneous Transluminal Angioplasty (PTA); Peripheral Vascular Disease Evaluation; Renal Artery Stenosis - Angiography and Stent Placement; Spiral CT for Lung Cancer Screening; Thermography;

Ultrasonography: Overview; Noninvasive cerebrovascular studies of extracranial arteries; Paranasal sinus ultrasonography; Spinal canal and contents ultrasonography; Peripheral Arterial Ultrasound Examination Using Pulsed Doppler; Peripheral Venous Ultrasound Examination; Thyroid and Parathyroid Ultrasonography;

Transrectal ultrasound for prostate or rectal cancer - biopsy/staging; Pelvic Ultrasound in Females; Sonohysterosalpingraphy; Obstetrical Ultrasonography; Scrotal Ultrasonography; Retroperitoneal Ultrasonography; Developmental Hip Dysplasia Detection by Ultrasonography; Ultrasound of peripheral sites (tibia, phalanges) for the selection of patients for pharmacologic treatment of osteoporosis; Radiology guideline resources/web links.

- Radiology Benefit Management: Web resources for radiology, nuclear medicine and radiation therapy provider manuals.

- Radiation Therapy/Oncology: Radiation oncology; Combination Chemotherapy and Radiation Therapy; Brachytherapy; Brachytherapy for the Prevention of Restenosis in Peripheral Arteries Following PTA of the Femoropopliteal System; Intracoronary Brachytherapy; Breast Conservation Therapy in the Management of Invasive Breast Cancer; Neutron Beam Radiotherapy; Proton Beam Radiotherapy; Stereotactic radiosurgery; Transperineal Brachytherapy for prostate cancer; Boron Neutron Capture Therapy (BNCT) For Glioblastoma Multiforme; Intensity Modulated Radiation Therapy; Radiation Therapy web sites.

- Skeletal-muscular system: Knee region: Arthroscopy - knee; Arthroscopic lavage or debridement, knee; Total Knee Replacement; Autologous chondrocyte transplantation surgery of the knee; Hyaluronidase, intra-articular injections for osteoarthritis;

Foot and ankle: Bunionectomy; Foot care - routine; Mycotic nails; Other covered services for the foot and ankle; Ingrown toe nails; Olecranon bursa aspiration; Plantar Keratosis; Interdigital Neuroma; Plantar fasciitis and heel spurs; Consultation services by a podiatrist - skilled nursing facility; Hammertoe surgery; Fractures of the toe; Maxwell-Brancheau Arthroereisis (MBA) Implant - for flat-foot;

Back and Neck: Acute cervical pain; Artificial Intervertebral Disc; Laminectomy ; Low back pain; Machines to test and treat low back pain; Chymopapain Chemonucleolysis; Endoscopic Anterior Spinal Surgery; Epidural injection of steroids for back pain; Facet Joint Injections; Facet Denervation, Facet Neurotomy, Facet Rhizotomy, or Articular Rhizolysis; Hypertonic saline for the treatment of epidural adhesions, adhesive arachnoiditis, or failed back syndrome; Implantable Infusion Pumps for Treatment of Chronic Severe Back Pain; Intradiscal Electrothermal Therapy (IDET); Laminectomy; Meniscectomy; Microdiscectomy; Percutaneous Lumbar Discectomy, including laser procedures; Percutaneous vertebroplasty and kyphoplasty; Prolotherapy; Spinal instability - Pedicle screw fixation; Spinal stenosis; Sacro-iliac Joint Injections; Chiropractic Medicine; Distraction osteosynthesis, Ilizarov method; Spinal manipulation under anesthesia;

Shoulder: Shoulder Arthrography; Arthroscopy, shoulder; Electrothermal arthroscopic repair for shoulder instability; Impingement Syndromes, Shoulder Bursitis, Rotator Cuff Tendinitis & Tears; Ultrasound therapy for calcific tendinitis of the shoulder;

Other Skeletal-muscular: Extracorporeal Shock Wave Therapy (ESWT) for musculo-skeletal conditions; Apligraft (R) (Graftskin) Medicare LMRP; Carpal tunnel release; Trigger Point Injections; Total Hip Replacement (THR) - Primary, excluding hip fracture, indications, LOS; Bone stimulators, electrical and low-intensity ultrasound; Gait analysis or the electrodynogram; Injection, tendon sheath, ligament, or trigger points or ganglion cyst; Injection of joints; Osteogenic protein-1 for the treatment of nonunion fractures;

- Urology - review criteria: Referral guidelines; BCG therapy for bladder cancer; Urinary FISH Test for Recurrent Bladder Cancer; Valrubicin for carcinoma in-situ of the bladder; Bladder stimulator/Pacemaker implantation; Bladder pacemakers; Bladder Capacity Ultrasound (Post-void Residual Measurements); Circumcision of the adult male; Cystoscopy; Bladder biopsy, transurethral;

Impotence evaluation and treatments: Viagra; Noninvasive suction devices; Papaverine injections; Penile prosthesis implantation; Electroejaculation; Internal Pudendal Arteriography (Angiography) for Erectile Dysfunction; Percutaneous Nephrostomy;

Prostate Cancer therapy; Prostate Cancer Screening Tests and Procedures; Prostate Specific Antigen (PSA); Benign Prostatic Hypertrophy - Treatment options; UroLume(R) endourethral prosthesis (urethral stent) for BPH, stenosis, strictures; Cryosurgical ablation of the prostate; Microwave therapy for BPH; Transurethral Resection of the Prostate (TURP); Transurethral Microwave Thermotherapy (TUMT) for BPH; Transurethral Radiofrequency Thermotherapy/Needle Ablation of the Prostate (TUNA); Water-Induced Thermotherapy (WIT); Shock wave lithotripsy (Extracorporeal shock wave lithotripsy);

Incontinence - defined; Artificial Urinary Sphincter; Stress incontinence - Electrical stimulation of the pelvic floor; Sacral nerve stimulation for urge incontinence; Transurethral/Periurethral collagen implantation for stress urinary incontinence; Marshall-Marchetti Kranz, Burch, Stamey and similar procedures; References - Urinary Incontinence; Transrectal ultrasound for prostate cancer - biopsy/staging; Renal Cryoablation; Transrectal ultrasound for prostate cancer; Transsexual surgery; Urethral Dilation - female; Urodynamic Testing;

- Vascular Laboratory: Noninvasive cerebrovascular studies of extracranial arteries; Carotid function - non-invasive tests: Duplex scan of carotid arteries; vertebral arteries; Ocular Plethysmography (OPG) and Ophthalmodynamometry; Transcranial doppler, Penile doppler and Corpora Cavernosography, Peripheral arterial non-invasive studies: Segmental Doppler Pressures and Pulse Volume Recording; Exercise (Stress) Doppler Test; Visceral arterial duplex imaging; Peripheral Arterial Duplex Scan; Digital Arterial Evaluation; Peripheral venous and arterial non-invasive studies/ultrasonography; Peripheral Arterial Ultrasound Examination Using Pulsed Doppler; AcuTect/Scintigraphic Imaging For Detection/Localization of Lower Limb Deep Vein Thrombosis;-- Hemorheograph.

- Addenda: Operational Standards; Delegation to PCPs; Delegation to SCPs; New Medical Technology Assessment - Policy/Procedure, Performance standards: QI/UM/Provider relations/Customer service; Critical Care - Medicare LMRP; Worker's Compensation; Hospital care 'length of stay' targets, by age range; Frequency by Diagnostic/Procedural Group, Length of stay targets by DRG; NY State Medicaid ALOS by DRG 2004; Surgical Procedures, LOS benchmarks; Outpatient procedures or 'Same-day discharge' authorization list;

- References and Resources: located throughout the manual - conveniently following each criteria or topic.

- Note: Review criteria guidelines or 'benefit interps' are useful resources for claims payment decisions to base medical necessity decisions, particularly when little or no preauthorization function or information exists as well as utilization management, educational and precertification tools. They should be distributed to relevant physicians and other providers for review, input and any needed change prior to implementation. All should be reviewed and approved by a Medical Policy Committee of the purchasing organization prior to use. Modification related to local clinical circumstances or terms of applicable certificates of coverage or provider contracts may be appropriate and necessary.

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Date:Feb 10, 2005
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