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Medical Policy Medical Records Documentation Guidelines

Medical Policy Medical Records Documentation Guidelines Medical record Documentation is frequently required to determine the Medical necessity for services described in Blue Cross Blue Shield of Texas (BCBSTX). Medical Policies. Medical record Documentation should be relevant to the member's Medical condition for the service(s) requested and should always include any specific Documentation requirements as outlined in the coverage section of the applicable Medical Policy . Standard Medical record Documentation may include but is not limited to the following: Comprehensive Medical history and physical examination Office or clinic notes Physician notes Laboratory reports In an effort to facilitate timely and accurate Medical record reviews, a number of Medical Policy Documentation forms have been developed.

claims review and processing, however providers are encouraged to request a ... providers in becoming knowledgeable of potential coverage issues. A Predetermination Request Form, along with the instructions for submitting a ... *Cranial Remolding Orthosis Device ...

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Transcription of Medical Policy Medical Records Documentation Guidelines

1 Medical Policy Medical Records Documentation Guidelines Medical record Documentation is frequently required to determine the Medical necessity for services described in Blue Cross Blue Shield of Texas (BCBSTX). Medical Policies. Medical record Documentation should be relevant to the member's Medical condition for the service(s) requested and should always include any specific Documentation requirements as outlined in the coverage section of the applicable Medical Policy . Standard Medical record Documentation may include but is not limited to the following: Comprehensive Medical history and physical examination Office or clinic notes Physician notes Laboratory reports In an effort to facilitate timely and accurate Medical record reviews, a number of Medical Policy Documentation forms have been developed.

2 These forms are not to be used as a replacement for, but as a supplement to Medical record Documentation . A complete listing of available Medical Policy Documentation forms can be viewed at: Documentation may be submitted upon claims submission in order to help expedite claims review and processing, however providers are encouraged to request a Predetermination review prior to rendering the services. A Predetermination review allows for a determination on Medical necessity of a service based on BCBSTX. Medical Policy and a member's contract benefits. Although groups or individual contracts do not generally require predetermination reviews, BCBSTX offers predeterminations in order to assist members, physicians and other professional providers in becoming knowledgeable of potential coverage issues.

3 A. Predetermination request Form, along with the instructions for submitting a predetermination, can be accessed on the BCBSTX web site at: Below is partial listing of Medical Policies that may require Medical record review . These, as well as all other Medical Policies can be viewed at any time via the BCBSTX website at: Test=true#hlink. page 1 of 10. * Medical Policy Documentation Form Available Click on Link Administrative Ambulance and Medical Transport Services Hospice Durable Medical Equipment Airway Clearance Devices Automatic External Defibrillators Continuous Passive Motion Device * cranial Remolding orthosis Device Home Apnea Monitor Home Prothrombin Time Monitors Hospital Beds and Related Equipment Knee Braces Lifts and Elevator Systems Low Intensity Ultrasound Accelerated Fracture Healing Device *Lower Limb Prosthetics, Including Microprocessor Prosthetics.

4 Meniett Low Pressure Pulse Generator for Meniere's Disease Negative Pressure Wound Therapy for the Treatment of Wounds . Oxygen for Home Use Prosthetics, Except Lower Limb Prosthetics Pulse Oximeter for Home Use Speech Generating Devices Therapeutic Lenses, Scleral Shell Traction Devices for Use in the Home *Wheelchairs and Accessories Medical : Alternative Modes of Nutrition in the Outpatient and Home Setting Ambulatory Cardiac Event Monitors including Mobile Cardiac Outpatient Telemetry . page 2 of 10. *Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Cancer Biventricular Pacing BRAF Gene Mutation Testing To Select Melanoma Patients for BRAF Inhibitor Targeted Therapy Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting Chromosomal Microarray (CMA) for the Genetic Evaluation of Patients with Developmental Delay (DD)/Intellectual Disability (ID) or Autism Spectrum Disorder (ASD) Cytochrome p450 (CYP450) Electroencephalograms Endovascular Grafts for Abdominal Aortic Aneurysms Endovascular Stent Grafts for Thoracic Aortic Aneurysms or Dissections.

5 Enhanced External Counterpulsation Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non- Small Cell Lung Cancer (NSCLC) Esophageal Monitoring Extracorporeal Membrane Oxygenation Genetic Testing for Alpha-1 Antitrypsin Deficiency Genetic Testing for Cardiac Disorders Genetic Testing for Cutaneous Malignant Melanoma (CNM) Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary Carcinoma of the Thyroid Genetic Testing for Hereditary Hemochromatosis Genetic Testing for Inherited Susceptibility to Colon Cancer Including Microsatellite Instability Genetic Tests (Miscellaneous) Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping Hypnosis Immune Cellular Function Assay to Monitor and Predict Immune Function.

6 Intraoperative Neurophysiological Monitoring Intravascular Brachytherapy for Prevention and Management of Restenosis after Percutaneous Transluminal Angioplasty JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer page 3 of 10. KRAS Mutation Analysis in Non-Small Cell Lung Cancer Laboratory Testing for HIV Tropism Lymphocyte Transformation Test Percutaneous and Implanted Nerve Stimulation and Neuromodulation Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines . Phrenic Nerve Implant Plethysmography Pneumatic Compression Devices Posterior Tibial Nerve Stimulation (PTNS) Prenatal and Preconception Genetic Tests Sexual Dysfunctions, Assessment and Treatment Sleep Related Breathing Disorders, Assessment and Diagnosis Tilt Table Testing Topographic Brain Mapping Transcranial Doppler Ultrasound Transendoscopic Therapies for Gastroesophageal Reflux Disease Treatment of Hyperhidrosis Mental Health: Autism Spectrum Disorders Biofeedback as a Treatment of Headache Electroconvulsive Therapy OB/GYN: Preimplantation Genetic Testing (PGT) Other.

7 Anti-Vascular Endothelial Growth Factor (VEGF) Inhibitors for use in the EYE . Intravitreal Corticosteroid Implants Ophthalmologic Techniques of Evaluating Glaucoma Orthoptics (Vergence/Accommodative therapy), Visual Exercises or Training . Photocoagulation of Macular Drusen Photodynamic Therapy for Subfoveal Choroidal Neovascularization Transpupillary Thermotherapy page 4 of 10. Prescription Drugs: Bevacizumab (Avastin) *Biologic Response Modifiers for the Treatment of Rheumatoid Arthritis and other Chronic Inflammatory Disease *Botulinum Toxin Cabazitaxel (Jevtana)* Cellular Immunotherapy for Prostate Cancer (Sipuleucel-T [Provenge]) CINRYZE [C1 Esterase Inhibitor (Human)] for Routine Prophylaxis of Hereditary Angioedema (HAE) Enzyme-replacement Therapy for Lysosomal Storage Disorders *Erythropoiesis-Stimulating Agents (ESAs) Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists *Growth Hormone Human Fibrinogen Concentrate (RiaSTAP) *Immunoglobulin (Ig)

8 Therapy (Including Intravenous [IVIG] and Subcutaneous IG [SCIG] Injectable Clostridial Collagenase for Fibroproliferative Disorders Ipilimumab (Yervoy) Mecasermin Recombinant (Increlex) Paclitaxel Protein-Bound Particles (Abraxane) Pegylated Interferon Therapy Plerixafor Injection (Mozobil) Progesterone Therapy as a Technique to Reduce Preterm Delivery in High-Risk Pregnancies Pulmonary Hypertension (PAH) Drug Therapies Recombinant and Autologous Platelet-Derived Growth Factors as a Primary Treatment of Wound Healing and other Miscellaneous Conditions Repository Corticotropin (ACTH) Injection *Respiratory Syncytial Virus Immunoprophylaxis Rituxan (Rituximab) for Treatment of Cancer and Hematologic Conditions.)

9 Soliris (eculizumab) Subcutaneous Hormone Implants Tysabri Xolair (Omalizumab) Ziconotide (Prialt) page 5 of 10. Radiology: Accelerated Partial Breast Irradiation after Breast-Conserving Surgery for Early Stage Breast Cancer Charged-Particle (Proton and Helium Ion) Radiation Therapy Computed Tomography (CT) Angiography (CTA) Using Advanced CT Systems . Endobronchial Brachytherapy Functional Magnetic Resonance Imaging Intensity Modulated Radiation Therapy Intraoperative Radiation Therapy (IORT) Lung Cancer Screening Using Computed Tomography (CT), Chest Radiographs, or Serial Sputum Cytology Magnetic Resonance Angiography (MRA) and Venography (MRV) Magnetic Resonance Imaging (MRI) of the Breast (BMRI) with or without Computer- Aided Evaluation (CAE) Magnetoencephalography (MEG) and Magnetic Source Imaging (MSI)

10 Non-Operative Spinal Ultrasound Percutaneous Vertebroplasty, Percutaneous Kyphoplasty, and Percutaneous Sacroplasty Positron Emission Tomography Radioembolization (Selective Internal Radiation Therapy) for Primary and Metastatic Tumors of the Liver Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) Scintigraphy of Acute Deep Venous Thrombus Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) . Video Fluoroscopic Evaluation of Velopharyngeal Closure Virtual Colonoscopy (VC), Computed Tomography Colonography (CTC) . Whole Body Computed Tomography (CT) Scan or Imaging as a Screening Test . Wireless Capsule Endoscopy Surgery: Aqueous Shunts for Glaucoma Artificial Intervertebral Disc page 6 of 10.


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