Member has 2 or more coronary heart disease (CHD) major risk factorsFootnote1*, and Member has low-density lipoprotein (LDL) cholesterol levels between 100 to 130 mg/dL; and Member has been judged to be at an intermediate-risk of cardiovascular disease by global risk assessment (i.e., 10...
Clinically evaluated, unexplained chronic fatigue cases can be classified as CFS if the member meets both of the following criteria: Clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (i.e., not lifelong), is not the result of ongoing exerti...
Member does not have any concomitant medical condition that would otherwise imminently contribute to deterioration of pulmonary status or undermine the expected benefits of the program (e.g., symptomatic coronary artery disease, congestive heart failure, myocardial infarction within the last 6 months, dy...
Footnote2** A nasal interface (mask or cannula type) may be used with a positive airway pressure device, with or without a head strap as an alternative to a full face mask. However, upgraded face mask is considered medically necessary only if there is documentation that the member needs a ...
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Evaluation of a member with an acute coronary event and hemodynamic instability, shock, or mechanical complications of the event; or In the setting of acute chest pain or equivalent symptoms with a high likelihood of being acute coronary syndrome, when there has been a diagnosis of acute myocardi...
Member is 18 years of age or older; and Member has bilateral nasal polyps and chronic symptoms of sinusitis despite intranasal corticosteroid treatment for at least 2 months unless contraindicated or not tolerated; and Member has one of the following: A bilateral nasal endoscopy, anterior rhinoscop...
Member is suffering the hemodynamic consequences of chronic atrial fibrillation/flutter despite adequate attempts at medical management;or Member is at high-risk for thromboembolism as evidenced byeither: A previous episode of thromboembolism when other sources of emboli have been ruled out,or ...
The member's medical records must clearly document the medical necessity for the test. It is not necessary to include documentation with each claim submission. Data gathered during NCS, however, should be available which reflect the actual numbers (latency, amplitude, etc.), preferably in a ...
Babesiosis if member has high-grade parasitemia (greater than or equal to 10 %), severe anemia (hemoglobin less than or equal to 10 g/dL), or hepatic, pulmonary, or renal compromise (red blood cell exchange); or Catastrophic antiphospholipid syndrome (APS with widespread thromboembolic disease...