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Clinical Coverage Guidelines

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Clinical Coverage Guidelines

last modified 11/19/2009 - 12:38 PM

Contributors: Keri Andersen

THERAPY GUIDELINES Physical, Occupational & Speech Therapy Coverage Guidelines (11/02/09)	PROCEDURE GUIDELINES Panniculectomy Guidelines (4/23/09) Reduction Mammoplasty Guidelines (5/11/09)	INTENSIVE SOCIAL SUPPORT SERVICES Criteria (4/13/07) Screening Form (4/30/07)
LABORATORY AND RADIOLOGY GUIDELINES Trofile Assay Guidelines (8/1/08)	OUT OF STATE Admission Guidelines (11/19/09) Urgent and Emergent Admission Form (09/24/09) Elective Pre-Admission Request Form (09/24/09) Psychiatric Inpatient Utilization Review Letter (08/04/09)
* DURABLE MEDICAL EQUIPMENT *
Apnea Monitor (04/01/09) Ambulation Assistive Devices (08/04/09) Blood Glucose Monitor Blood Pressure Set-Up: Sphygmomanometer with Cuff and Stethoscope Breast Pumps (03/15/07) Car Seats (08/04/09) Circulatory Aids Compression Garments (06/01/08) Continuous Passive Motion Device (CPM) Enteral Nutrition Enuresis Alarm Excess Supplies (diapers, catheters, dressings, etc.)	External Infusion Pump Home Uterine Monitor Humidifiers Jaw Motion Rehabilitation Device (09/24/09) Nebulizer Neuromuscular Stimulator Nutritional Supplements Oximeters Oximeter Criteria (11/15/06) Oximeter Prescription Form (10/02/06) Oxygen Services Parrafin Bath Parenteral Nutrition Pediatric Scales (09/30/09) Repairs/Modifications for DME Stander	Suction Device Traction Ambulatory Cervical Extremity Pelvic Transfer Board and Other Devices Trapeze and Other Bed Mobility Toileting Equipment (07/15/09) Ultraviolet Light Ventilator and Accessories Vision Care (08/04/09)

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