Procedures with potential to be investigational or experimental or not
standard of care such as:
EBCT (Electron-Beam Computer Tomography)
IDET (Intradiscal Electrothermal Treament-OP)
IVIG (Intravenous Immunoglobulin)
- Medical record documentation indicating history of
current medical condition and medical necessity of the proposed treatment.
- Past conservative treatments tried and failed.
- Peer reviewed literature to show efficacy of
treatment - optional.
- Any additional information the provider would like to be considered for review.
Once pre-determination has been made, letters are sent to the Employee, Provider of Service
and Primary Care Provider.