Medical Review Criteria Guidelines for Managed Care (12th edition, 2013)

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An important 2-volume resource for utilization management and claims departments to improve care and cost-savings . 1,260 pages include more than 1,750 detailed clinical review criteria guidelines, evidence-based benefit interpretations listing specific indications for medically necessary ambulatory care or inpatient tests and procedures + Length of Stay by DRG tables; extensive authoritative references and resource links. Extensive references follow each guideline. Additional resources include LOS benchmarks by DRG for Medicare, commercial and Medicaid populations.

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.

"The Bible" for health plan benefit interpretation guidelines. This is a critical comprehensive resource for clinical review determinations.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; Choosing Wisely

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; Patient Controlled Analgesia (PCA); 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,

Cardiopulmonary exercise testing; 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, Esophageal Doppler Monitoring, 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;

Fractional Flow Reserve Prior to Coronary Artery Revascularization; Hypothermai following cardiac arrest, therapeutic; Hypertrophic Cardiomyopathy; Implantable Left Atrial Hemodynamic Monitor; Pediatric cardiac catheterization guideline; Carotid Sinus Stimulation for Hypertension; Remote Ischemic Conditioning; Intensive Behavioral Therapy for Cardiovascular Disease; Arterial Elasticity Measurement (Non-invasive) for Cardiovascular Disease;

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; Remote Monitoring in HF with Implantable Defibrillators; Stem cell therapy for cardiac disease; 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 artery percutaneous stents; 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; Endocarditis – Surgical Management; Extracranial-Intracranial arterial bypass surgery; Heart transplant; Heart volume reduction surgery (partial ventriculectomy); Heartsbreath test for cardiac transplant rejection

Impedance plethysmography; Intermittent claudication; Intracoronary Hyperoxemic Therapy; 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; Peripheral Vascular Disease Screening; 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; Pseudoaneurysms, Thrombin injection; Pulmonary arterial shunts – balloon angioplasty

Renal Artery Stenosis – Angioplasty, Stent Placement; Rib, fracture management; Robotically-assisted cardiac surgery;

Stents; Thoracoscopic aortopexy for tracheomalacia

Thrombectomy, arterial or venous; Mechanical embolectomy for acute ischemic stroke; 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;

Vena Cava Filters; 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;

Hemangiomas ; Herpes Simplex; Herpes Zoster; Hyperhidrosis therapy; Hair Loss/Alopecia; Impetigo and pyoderma; Inflammatory dermatosis/'Rashes'; 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; Pityriasis versicolor;

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; Telangectasia, Ulcers & Hyperkeratosis; Verruca Vulgaris/ Warts; Vitiligo; Ultraviolet A Light Therapy; Ultraviolet B Light Therapy; Dermatology notes.

Please contact us to get the complete Table of Contents.To order this report:Pathology Industry: Medical Review Criteria Guidelines for Managed Care (12th edition, 2013)

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