Diagnostic Criteria a. All provider claims are restricted to claims for Enrollees with an ICD-9CM diagnosis code of 290 through 290.43; 293 through 298.9; 300 through 301.9; 302.7, 306.51 through 312.4; 312.81 through 314.9; 315.3, 315.31, 315.5, 315.8, and 315.9.
Diagnostic Criteria. Severity Level Medical Verification Requirements A0 & A1 Physician Diagnosis of Qualifying Injury in the COPD disease group. A2 to A4 Spirometry tests: Post-bronchodilator FEV1/FVC ≤0.7 (≤70%) (use post-BD when possible; otherwise, use pre-BD value) Source: European Respiratory Society/American Thoracic Society COPD Guidelines – 2005 OR For Emphysema only, a CT Scan that states as a conclusion any or all of the following: Emphysema (panlobular, panacinar or paraseptal), Bullous disease, or giant bullae; provided, however, that conclusions on a CT Scan reflecting mild or minor emphysematous changes, air-trapping, pneumatoceles, cysts or cystic disease, and/or bronchiectasis shall not qualify.
Diagnostic Criteria. Severity Level Medical Verification Requirements B0 to B4 Chest CT or X-ray finding supporting such diagnosis, such as bibasilar reticular abnormalities (e.g., increased interstitial markings, honey-combing, hazy opacifications that are worse in the subpleural and inferior regions) with or without ground glass opacities or a lung biopsy that supports said diagnosis. Source: ATS/ERS Criteria for Diagnosis of Idiopathic Pulmonary Disease in Absence of Surgical Lung Biopsy
Diagnostic Criteria. Severity Level Medical Verification Requirements C0 & C1 Physician Diagnosis of Qualifying Injury in the Asthma/RADS disease group. C2 to C4 Pulmonary Function Test (PFT): Pre-bronchodilator FEV1 of <80% predicted, and Post-bronchodilator FEV1 improvement of 12% or 250 cc; OR Positive Methacholine Challenge Test (MCT): ≥20% decrease in FEV1 at or below 8 mg/ml Sources: Global Initiative for Asthma/World Health Organization; American College of Chest Physicians Consensus Statement
Diagnostic Criteria. Severity Level Medical Verification Requirements D0 & D1 Physician Diagnosis of Qualifying Injury in the Laryngitis/Pharyngitis disease group. D2 & D3 Physical examination or endoscopy, including Laryngoscopy or Pharyngoscopy finding redness, inflammation and/or swelling of pharyngeal or laryngeal mucosal membranes.
Diagnostic Criteria. Severity Level Medical Verification Requirements
Diagnostic Criteria. Severity Level Criteria F0 to F2 Physician Diagnosis of a Qualifying Injury in the Upper Digestive disease group.
Diagnostic Criteria. Level Criteria H0 to H2 Death of the Primary Plaintiff established by a certificate, hospital notes, or other authoritative document (e.g., physician letter) confirming death.
Diagnostic Criteria. Level Criteria I0 to I3 Histopathology report documenting pre-cancerous or cancerous condition; OR Physician documentation of diagnosis of or treatment for pre-cancerous or cancerous condition.
Diagnostic Criteria. Level Criteria J0 to J2 Physician documentation of diagnosis of or treatment for hypertension, heart attack, or miscellaneous cardiac condition.
