Practice Guidelines

Table of Contents

Policy and Procedure Review	Review
Prior Authorization of Same Day Surgical Procedure	1
Prior Authorization of Inpatient Hospital Admissions	1A
Health Care Services Denial	2
Health Choices Denial	2A
Transplants	3
Nutritional Therapy	4
Breast MRI Guidelines	5
Hospice Care Guidlines	6
Referral Authorization	7
Pharmacy Benefit Information for Members	8
Emergency Room Coverage	9
Approval of Out-of-Area Care/Students, Vacationers, Snowbirds	10
Concurrent Hospital Review	11
Procurement of Durable Medical Equipment	12
Diabetic Shoes	13
Cochlear Implants	14
Health Choice Appeal	15
Health Choice Stop-Loss	16
Case Management and Discharge Planning	17
Post Admission Outcome Survey	17A
Vagus Nerve Stimulation Therapy	18
Drug Formulary	46
Confidentiality of Patient Information	57
Criteria Utilized in Determination of Medical Necessity	60
Communication of Quality Concerns Identified During Hospital Concurrent Review	61
Procedures for Verifying Utilization Review Consistency	62
Determining Coverage of Advancing Medical Technology	64
Qualifications/Credential Requirments for Health Care Services Case Managers	65
Generating Letters to Subscribers for Retroactively Approved Claims	66
Tumor Chemosensitivity and Chemoresistance Assays	67
Chief Medical Officer Absence	71
Criteria for the Coverage of Reduction Mammoplasy	72
Retrospective Review	74
Mental Health/Chemical Dependency Triage Personnel Credential Requirements	76
Mental Health/Chemical Dependency Access Standards	77
Step Down/Skilled Care	78
Delegation of UM Activities	79
Prior Authorization	80
Obstructive Sleep Apnea Syndrome	81
Prior Authorization of Prescription Drugs	82
Drug Recalls	83
Communication Services	84
Bariatric Surgery	88
External Insulin Pumps	89
Hyperbaric Oxygen Therapy (HBO)	90
Genetic Testing	91
Endoscopy: Wireless Video Capsule Endoscopy	92
Treatment of Hyperhidrosis	93
Medicare Medical Review Process	94
Uroplasty Criteria	95
Continuous Glucose Mointoring Systems	96

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