Provider Forms > Medical Info Required for Pre-Determination > Procedures with potential to be investigational or experimental or not standard of care
 

Procedures with potential to be investigational or experimental or not standard of care such as:

Clinical Trials

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.

Reviewed 2/26/04

 

 

 

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