![]() ![]() Support for Social Determinants of Health These guidelines, organized by common diagnoses and conditions, include referral to specialists as well as indications for emergency evaluation. Referral management guidelines to support the primary care provider’s decision to refer patients for specialty care. Rehabilitationĭecision support for different rehabilitation evaluations, modalities, and services, as well as a Rehabilitation Visit Table that presents benchmarks for the number of rehabilitation visits needed per treatment episode of various common diagnoses. Guidelines for high-cost pharmacologic agents, including chemotherapeutic agents, hematologic agents, monoclonal antibodies, hormonal agents, and botulinum toxins. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)Įvidence to support requests for wheelchairs and scooters, specialty beds and mattresses, CPAP/BPAP, and other medical equipment. Procedures and diagnostic testsĮvidence-based criteria for determining the medical necessity of established and emerging procedures and diagnostic tests that usually take place in ambulatory care or outpatient settings. Genetic MedicineĬomprehensive guidance (including opioid pharmacogenetics) to determine whether genetic tests and gene panels are clinically appropriate or whether insufficient evidence exists to support their use in guiding clinical decision making. ImagingĬlinical indications for various imaging tests, including PET, CT scanning, CT angiography, MRI, MR angiography, nuclear medicine, ultrasound, catheter angiography, barium studies, osteoporosis screening, and noninvasive vascular diagnostic studies. Assess, Treat, Manage, and Make Referrals AppropriatelyĪmbulatory Care is a comprehensive compilation of guidelines (evidence-based authorization guidelines and referral management guidelines) for established and emerging procedures and technologies used primarily in ambulatory or outpatient settings.
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