Ambulatory Care

Ambulatory Care

Evidence-based Authorization

Ambulatory Care guidelines address:

  • Imaging – Precise, actionable indications for imaging tests, such as CT scans and CT angiographies. Users can search using CPT or HCPCS codes.
  • Procedures and diagnostic tests – Criteria for established and emerging procedures and tests, including genetic medicine.
  • Durable medical equipment, prosthetics, orthotics, and supplies – Decision support covering wheelchairs, scooters, specialty beds, and other durable medical equipment.
  • Injectables and other pharmacologic agents – More than 70 guidelines for high-cost pharmacologic agents.
  • Rehabilitation – Authorization guidelines and treatment planning for rehabilitation evaluations, modalities, and services, including benchmark data for the number of rehabilitation visits needed per treatment episode of various common diagnoses.
  • Referral management – Guidance for referral of patients from primary care providers to specialists, organized by common diagnoses and conditions.
 
Qualified healthcare professionals may use our guidelines as a tool to support medical necessity decisions, but they should not use them as the sole basis for denying treatment or payment. Our guidelines must be applied to individual patients on a case-by-case basis and always in the context of a qualified healthcare professional's clinical judgment. 
 
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