26th Edition (Archived)

26th

2022-AC-101

Ambulatory Care

Traction, Spine

 Rehabilitation > Therapeutic Modalities

A-0345

Orthopedics

Back Pain

Adult

26th

2022-AC-102

Ambulatory Care

Lower Limb Prosthesis

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) > Musculoskeletal Conditions

A-0487

Musculoskeletal Disease

Lower Limb Prosthesis

Adult

26th

2022-AC-103

Ambulatory Care

Non-Small Cell Lung Cancer – Gene Testing (Somatic or Therapeutic)

Genetic Medicine > Oncology

A-0795

Oncology

Non-Small Cell Lung Cancer

Adult

26th

2022-AC-104

Ambulatory Care

Aphasia Rehabilitation

Rehabilitation > Speech-Language Pathology Services

A-0554

Neurology

Aphasia Stroke Related

Adult

26th

2022-AC-105

Ambulatory Care

Guselkumab

Specialty Medications > Autoimmune Conditions

A-0972

Immunology - Rheumatology

Psoriatic Arthritis

Adult

26th

2022-AC-106

Ambulatory Care

Abdominal Ultrasound

 Imaging > Ultrasound

A-0100

Gastroenterology

Cholecystitis

Adult

26th

2022-AC-107

Ambulatory Care

Hysteroscopy, w/wo Endometrial resection, Ablation/Myeomectomy

 Procedures and Diagnostic Tests > Obstetrics and Gynecology

A-0286

Gynecology

Menorrhagia

Adult

26th

2022-AC-108

Ambulatory Care

Chronic Pelvic Pain, Women - Referral Management

 Referral Management > Women’s Health Conditions

R-0145

Gynecology

Dysmenorrhea

Adult

26th

2022-ISC-101

Inpatient & Surgical Care

Chronic Obstructive Pulmonary Disease: Observation Care

 Observation Care Guidelines

OC-010

Pulmonology

Chronic Obstructive Pulmonary Disease

Adult

26th

2022-ISC-102

Inpatient & Surgical Care

Gastrointestinal Bleeding, Lower: Observation Care

 Observation Care Guidelines

OC-020

Gastroenterology

Lower Gastrointestinal Bleeding

Adult

26th

2022-ISC-103

Inpatient & Surgical Care

Viral Illness, Acute: Observation Care/Viral Illness, Acute

 Observation Care Guidelines/Optimal Recovery Guidelines

OC-064

M-280

Pulmonology

COVID-19 Infection

Adult

26th

2022-ISC-104

Inpatient & Surgical Care

Cellulitis: Hospital-at-Home

 Optimal Recovery Guidelines > Hospital at Home

M-70-HaH

Infectious Disease

Cellulitis

Adult

26th

2022-ISC-105

Inpatient & Surgical Care

Failure to Thrive

 Optimal Recovery Guidelines > Pediatrics

P-187

Pediatrics

Failure to Thrive

PEDIATRIC

26th

2022-ISC-106

Inpatient & Surgical Care

Stroke: Ischemic

 Optimal Recovery Guidelines > Neurology

M-83

Neurology

Ischemic Stroke

Adult

26th

2022-ISC-107

Inpatient & Surgical Care

Mastectomy, Complete

 Optimal Recovery Guidelines > General Surgery

S-860

General Surgery-Oncology

Breast Cancer

Adult

26th

2022-ISC-108

Inpatient & Surgical Care

Newborn Care, Term, with Severe Illness or Abnormality

 Optimal Recovery Guidelines > Neonatology

P-595

Neonatology

Meconium Aspiration

Neonatology

26th

2022-RRG-101

Rapid Review Guidelines

Pneumonia RRG

Rapid Review Guidelines > Adult > Thoracic Surgery and Pulmonary Disease

M-282-RRG

Pulmonology

Pneumonia

Adult

26th

2022-RRG-102

Rapid Review Guidelines

Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion RRG

Rapid Review Guidelines > Adult > Cardiology

M-157-RRG

Cardiology

Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD)

Adult

26th

2022-MCM-101

Multiple Condition Management

Pneumonia with Clinically Active Chronic Obstructive Pulmonary Disease and Clinically Active Diabetes MCM

Multiple Condition Management

M-282-CPDM

Multiple Active Conditions

Multiple Active Conditions

Adult

26th

2022-GRC-101

General Recovery Care

Problem Oriented General Recovery Guidelines > Wound and Skin Management GRG

General Recovery Guidelines

PG-WS

Skin and Wound Conditions

Thermal Burn

Adult

26th

2022-GRC-103

General Recovery Care

Body System General Recovery Guidelines > Urologic Surgery or Procedure GRG

General Recovery Guidelines

SG-US

Urology

Intersex Female to Male

Adult

26th

2022-HC-101

Home Care

Venous Thromboembolism

 Optimal Recovery Guidelines > Thoracic Surgery and Pulmonary Disease

M-2290

Pulmonology

Pulmonary Embolism; Deep Vein Thrombosis

Adult

26th

2022-HC-102

Home Care

Laryngectomy

 Optimal Recovery Guidelines > Head and Neck Surgery

S-2780

Head and Neck Surgery

Laryngectomy

Adult

26th

2022-HC-103

Home Care

Private Duty Nursing

Private Duty Nursing

PDN-2001

Private Duty Nursing

Spina Bifida/Stroke

Adult

26th

2022-HC-104

Home Care

Private Duty Nursing

Private Duty Nursing

PDN-2001

Private Duty Nursing

Chromosome 19 Abnormalities

PEDIATRIC

26th

2022-RFC-101

Recovery Facility Care

Urinary Tract Infection

Optimal Recovery Guidelines > Subacute/Skilled Nursing Facility (SNF) > Urology

M-7090

Urology

Urinary Tract Infection (UTI)

Adult

26th

2022-RFC-102

Recovery Facility Care

Bowel Surgery: Small Intestine Resection

Optimal Recovery Guidelines > Subacute/Skilled Nursing Facility (SNF) > General Surgery

S-5250

Gastroenterology

Small Bowel Resection

Adult

26th

2022-RFC-103

Recovery Facility Care

Inpatient Rehabilitation Facility (Acute Rehabilitation): Burns

 Optimal Recovery Guidelines > Inpatient Rehabilitation Facility (IRF) > Skin and Wound Care

I-7009

Skin and Wound

Burn

Adult

26th

2022-RFC-104

Recovery Facility Care

Mastectomy

 Optimal Recovery Guidelines > Subacute/Skilled Nursing Facility (SNF) > General Surgery

S-5858

General Surgery

Breast Cancer

Adult

26th

2022-BHC-101

Behavioral Health Care

Bulimia Nervosa, Binge-Eating Disorder, and Other Specified Feeding or Eating Disorders, Child or Adolescent: Inpatient Care

Care Guidelines for Behavioral Health > Bulimia Nervosa, Binge-Eating Disorder, and Other Specified Feeding or Eating Disorders

B-021-IP

Behavioral Health - Pediatrics

Bulimia Nervosa

PEDIATRIC

26th

2022-BHC-102

Behavioral Health Care

Trigeminal Nerve Stimulation, Transcutaneous: Behavior Health Care

Therapeutic Services

B-820-T

Behavioral Health

Major Depression

Adult

26th

2022-BHC-103

Behavioral Health Care

Dementia: Partial Hospital Program

Care Guidelines for Behavioral Health > Dementia

B-007-PHP

Behavioral Health

Early-Onset Alzheimer’s

Adult

26th

2022-BHC-104

Behavioral Health Care

Anorexia Nervosa: Residential Care

Care Guidelines for Behavioral Health > Anorexia Nervosa

B-001-RES

Behavioral Health - Pediatrics

Anorexia Nervosa

PEDIATRIC

26th

2022-BHC-105

Behavioral Health Care

Outpatient Opioid Maintenance Therapy

Behavioral Health Level of Care Guidelines

B-910-OPD

Behavioral Health

Opioid Management

Adult

26th

2022-BHC-106

Behavioral Health Care

Bipolar Disorders, Adult: Inpatient Care

Care Guidelines for Behavioral Health

B-004-IP

Behavioral Health

Bipolar Disorders

Adult

26th

2022-AC-201

Ambulatory Care

Seat Cushions, Alternating Pressure Support

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) > Skin Conditions

 A-0349

Skin and Wound

Skin and Wound

Adult

26th

2022-AC-202

Ambulatory Care

Infusion Pump

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) > Miscellaneous Conditions

 A-0618

Infectious Condition

Infected Prosthetic Mitral Valve

Adult

26th

2022-AC-203

Ambulatory Care

Epilepsies (Hereditary)-Gene Panels

Genetic Medicine > Neurology

 A-0905

 Neurology

Epilepsy

PEDIATRIC

26th

2022-AC-204

Ambulatory Care

Spinal Manipulation Therapy (SMT), Chiropractor & Other

Rehabilitation > Speech-Language Pathology Services

 A-0331

 Musculoskeletal

Spinal Manipulation

 Adult

26th

2022-AC-205

Ambulatory Care

Axicabtagene Ciloleucel

Specialty Medications > Oncologic Conditions

 A-1030

Oncology - Pediatrics

B-cell Acute Lymophoblastic Leukemia

PEDIATRIC

26th

2022-AC-206

Ambulatory Care

Brain Positron Emission Tomography (PET)

Imaging > Positron Emission Tomography (PET)

 A-0096

Neurology

Dementia

Adult

26th

2022-AC-207

Ambulatory Care

Transesophageal Echocardiography (TEE)

Procedures and Diagnostic Tests > Cardiology

 A-0112

 Cardiology

Subacute Bacterial Endocarditis

Adult

26th

2022-AC-208

Ambulatory Care

Infertility - Referral Management

Referral Management > Women’s Health Conditions

 R-0193

 Gynecology

Infertility

Adult

26th

2022-ISC-201

Inpatient & Surgical Care

Drug Ingestion or Overdose: Observation Care

Observation Care Guidelines

 OC-017

Neurology

Overdose 

Adult

26th

2022-ISC-202

Inpatient & Surgical Care

Pneumothorax: Observation Care

Observation Care Guidelines

 OC-031

Pulmonology

Pneumothorax

Adult

26th

2022-ISC-203

Inpatient & Surgical Care

Pelvic Inflammatory Disease, Acute: Observation Care / Pelvic Inflammatory Disease, Acute

Observation Care Guidelines / Optimal Recovery Guidelines > Obstetrics and Gynecology

 OC-028/M-260

Gynecology

Pelvic Inflammatory Disease

Adult

26th

2022-ISC-204

Inpatient & Surgical Care

 Hip: Congenital Dislocation, Open Reduction

Optimal Recovery Guidelines > Pediatrics

 P-590

Surgery - Pediatrics

Congenital Hip Dislocation

PEDIATRIC

26th

2022-ISC-205

Inpatient & Surgical Care

Chronic Obstructive Pulmonary Disease: Hospital at Home

Optimal Recovery Guidelines > Hospital at Home

M-100-HaH 

Pulmonology

Chronic Obstructive Pulmonary Disease

Adult

26th

2022-ISC-206

Inpatient & Surgical Care

Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy

Optimal Recovery Guidelines > Obstetrics and Gynecology

 S-775

Gynecology

Elective Bilateral Salpingo-oophorectomy for BRCA1 Gene Mutation

Adult

26th

2022-ISC-207

Inpatient & Surgical Care

Gastroenteritis, Diarrhea with Dehydration, or Dysentery, Pediatric

Optimal Recovery Guidelines > Pediatrics

 P-190

Gastroenterology - Pediatrics

Gastroenteritis

PEDIATRIC

26th

2022-ISC-208

Inpatient & Surgical Care

Venom Exposure from Bite or Sting

Optimal Recovery Guidelines > Infectious Disease

 M-610

Infectious Condition

Pit Vapor Snake Bite

Adult

26th

2022-RRG-201

Rapid Review Guidelines

Failure to Thrive RRG

Rapid Review Guidelines > Pediatric > Gastroenterology

 P-187-RRG

Gastroenterology -  Pediatric

Failure to Thrive

PEDIATRIC

26th

2022-RRG-202

Rapid Review Guidelines

Mastectomy, Complete RRG

Rapid Review Guidelines > Adult > General Surgery

S-860-RRG

Surgery

Complete Mastectomy

Adult

26th

2022-MCM-201

Multiple Condition Management

Drug Ingestion / Overdose with Alcohol Misuse MCM 

Multiple Condition Management

M-153-AL

 Multiple Active Conditions

Overdose with Alcohol Misuse

Adult

26th

2022-GRG-201

General Recovery Care

Medical Oncology GRG

Problem Oriented General Recovery Care

 PG-ONC

 Oncology

Mesothelioma

Adult

26th

2022-GRG-202

General Recovery Care

General Surgery or Procedure GRG

Body System General Recovery Guidelines

 SG-GS

Surgery - Pediatrics

Ladd Procedure for Intestinal Ischemia

PEDIATRIC

26th

2022-HC-201

Home Care

Pancreatitis, with Common Duct Stone

 Optimal Recovery Guidelines > Gastroenterology

 M-2251

Gastroenterology

Pancreatitis

Adult

26th

2022-HC-202

Home Care

Amyotrophic Lateral Sclerosis (ALS)

Optimal Recovery Guidelines > Neurology

 M-4010

Neurology

Amyotrophic Lateral Sclerosis

Adult

26th

2022-HC-203

Home Care

Private Duty Nursing

Private Duty Nursing

 PDN-2001

Private Duty Nursing

Amyotrophic Lateral Sclerosis

Adult

26th

2022-HC-204

Home Care

 Failure to Thrive

Optimal Recovery Guidelines > Pediatrics

 P-2187

Gastroenterology - Pediatrics

Failure to Thrive

PEDIATRIC

26th

2022-RFC-201

Recovery Facility Care

Geriatric Admission Recovery Facility Care GRG

RFC General Recovery Guidelines

 GRG-GER-RF

Oncology

Multiple Myeloma/Bone Marrow Transplant

Adult

26th

2022-RFC-202

Recovery Facility Care

Optimal Recovery Guidelines>Subacute/Skilled Nursing Facility (SNF) > Neurology

Optimal Recovery Guidelines > Subacute/Skilled Nursing Facility (SNF) > General Surgery

 M-5083

 Neurology

Stroke

Adult

26th

2022-RFC-203

Recovery Facility Care

 Meningitis

Optimal Recovery Guidelines > Subacute/Skilled Nursing Facility (SNF) > Neurology

M-52221 

 Neurology

Meningitis 

Adult

26th

2022-RFC-204

Recovery Facility Care

Pancreatectomy

Optimal Recovery Guidelines > Subacute/Skilled Nursing Facility (SNF) > General Surgery

S-6200 

 Surgery

Pancreatectomy

Adult

26th

2022-BHC-201

Behavioral Health Care

Other Psychotic Disorders, Adult: Inpatient Care

 Care Guidelines for Behavioral Health > Other Psychotic Disorders

 B-011-IP

 Behavioral Health

Other Psychotic Disorders

Adult

26th

2022-BHC-202

Behavioral Health Care

Vagus Nerve Stimulation, Implantable: BHC

 Therapeutic Services

 B-821-T

 Behavioral Health

Vagus Nerve Stimulation, Implantable

Adult

26th

2022-BHC-203

Behavioral Health Care

Bulimia Nervosa, Binge-Eating Disorder, and Other Specified Feeding or Eating Disorders: Outpatient Care

 Care Guidelines for Behavioral Health > Bulimia Nervosa, Binge-Eating Disorder, and Other Specified Feeding or Eating Disorders

 B-005-AOP

Behavioral Health - Pediatric

Bulimia

PEDIATRIC

26th

2022-BHC-204

Behavioral Health Care

Anxiety Disorders: IOP

Care Guidelines for Behavioral Health

 B-002-IOP

Behavioral Health

Anxiety

Adult

26th

2022-BHC-205

Behavioral Health Care

Crisis Intervention Behavioral Health Level of Care

 Behavioral Health Level of Care Guidelines

 B-905-CI

 Behavioral Health - Pediatric

Crisis Intervention/Depression

PEDIATRIC

26th

2022-BHC-206

Behavioral Health Care

Schizophrenia Spectrum Disorders, Child or Adolescent: Inpatient Care

Care Guidelines for Behavioral Health > Schizophrenia Spectrum Disorders

B-027-IP

Behavioral Health - Pediatric

Schizophrenia

PEDIATRIC

26th

2022-AC-301

Ambulatory Care

Tongue Base Ablation, Radiofrequency and Other Tongue Procedures

Procedures and Diagnostic Tests > Head and Neck Surgery

A-0249

Head and Neck Surgery

Obstructive Sleep Apnea

Adult

26th

2022-AC-302

Ambulatory Care

Scooters

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) > Musculoskeletal Conditions

A-0352

Musculoskeletal Condition

Chronic Obstructive Pulmonary Disease and Severe Osteoarthritis

Adult

26th

2022-AC-303

Ambulatory Care

Familial Hypercholesterolemia - APOB, LSLR, and PCSK9 Genes

Genetic Medicine > Cardiology

A-0958

Hematology -Oncology

Hemachromatosis

Adult

26th

2022-AC-304

Ambulatory Care

Modified Barium Swallow Study

Rehabilitation > Diagnostics

A-0329

Musculoskeletal Condition

Dysphagia

Adult

26th

2022-AC-305

Ambulatory Care

Onabotulinumtoxin A

Specialty Medications > Neurologic Conditions

A-0296

Head and Neck Condition

Laryngeal Dystonia

Adult

26th

2022-AC-306

Ambulatory Care

Shoulder MRI

Imaging > MRI

A-0056

Orthopedics

Chronic Shoulder Pain

Adult

26th

2022-AC-307

Ambulatory Care

Uvulopalatopharyngoplasty (UPPP) 

Procedures and Diagnostic Tests > Head and Neck Surgery

A-0245

Head and Neck Surgery

Obstructive Sleep Apnea

Adult

26th

2022-AC-308

Ambulatory Care

Acoustic Neuroma - Referral Management

Referral Management > Ear, Nose, and Throat Conditions

R-0193

Neurosurgery

Sensory Hearing Loss

Adult

26th

2022-ISC-301

Inpatient & Surgical Care

Heart Failure: Observation Care

Observation Care Guidelines

OC-024

Cardiology

Heart Failure

Adult

26th

2022-ISC-302

Inpatient & Surgical Care

Asthma: Observation Care

Observation Care Guidelines

OC-004

Pediatrics

Asthma

PEDIATRIC

26th

2022-ISC-303

Inpatient & Surgical Care

Pancreatitis: Observation Care/ Pancreatitis

Observation Care Guidelines/Optimal Recovery Guidelines > Gastroenterology

OC-065/M-250

Gastroenterology

Pancreatitis

Adult

26th

2022-ISC-304

Inpatient & Surgical Care

Urinary Tract Infection (UTI): Hospital-at-Home

Optimal Recovery Guidelines

M-300-HaH

Urology

Urinary Tract Infection

Adult

26th

2022-ISC-305

Inpatient & Surgical Care

Sepsis and Other Febrile Illness, without Focal Infection

Optimal Recovery Guidelines > Pediatrics

 P-410

Pediatrics

Sepsis

 PEDIATRIC

26th

2022-ISC-306

Inpatient & Surgical Care

Seizure, Pediatric

Optimal Recovery Guidelines > Pediatrics

 P-390

Pediatrics

Seizure

PEDIATRIC

26th

2022-ISC-307

Inpatient & Surgical Care

Sepsis and Other Febrile Illness, without Focal Infection

Optimal Recovery Guidelines > Infectious Disease

 M-160

Infectious Disease Condition

Sepsis

Adult

26th

2022-ISC-308

Inpatient & Surgical Care

Retinal Detachment Repair

Optimal Recovery Guidelines > Ophthalmology

 S-1030

Other Condition

Detached Retina Repair

Adult

26th

2022-ISC-309

Inpatient & Surgical Care

Bronchiolitis

Optimal Recovery Guidelines

P-80

Pediatrics

Bronchiolitis

PEDIATRIC

26th

2022-ISC-310

Inpatient & Surgical Care

Neonatal Abstinence Syndrome

Optimal Recovery Guidelines > Neonatology

P-155

Pediatrics

Neonatal Abstinence Syndrome - Oxycodone

PEDIATRIC

26th

2022-RRG-301

Rapid Review Guidelines

Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy RRG

Rapid Review Guidelines > Adult > Gynecology

S-775-RRG

Gynecology

Prophylactic Laparoscopic Bilateral Salpingo-oophorectomy

Adult

26th

2022-RRG-302

Rapid Review Guidelines

Gastroenteritis, Diarrhea with Dehydration, or Dysentery, Pediatric RRG

Rapid Review Guidelines > Pediatric > Gastroenterology

P-190-RRG

Pediatrics

Pediatrics/Gastroenteritis 

PEDIATRIC

26th

2022-MCM-301

Multiple Condition Management

Gastroenteritis with Clinically Significant Dementia MCM

Multiple Condition Management

M-170-DE 

Multiple Active Conditions

Gastroenteritis with Dementia

Adult

26th

2022-GRC-301

General Recovery Care

 Ventilator Management Long-Term Acute Care Hospital (LTACH) Guideline

General Recovery Care > Long-Term Acute Care Hospital (LTACH) General Recovery Guidelines

GRG-049

Pulmonology

Respiratory Distress with COPD and Ventilator 

Adult

26th

2022-GRC-302

General Recovery Care

Neonatology GRG

General Recovery Guidelines > Problem Oriented General Recovery Guidelines

 PG-NEO

Neonatology

Down Syndrome (Trisomy 21)

PEDIATRIC

26th

2022-HC-301

Home Care

 Septic Arthritis

Optimal Recovery Guidelines > Infectious Disease

 M-2605

Infectious Disease Condition

Septic Arthritis

Adult

26th

2022-HC-302

Home Care

 Femur Fracture

Optimal Recovery Guidelines > Orthopedics

 S-2490

Orthopedics

Femur Fracture

Adult

26th

2022-HC-303

Home Care

Gastric Obesity Surgery

Optimal Recovery Guidelines > General Surgery

 S-2512

General Surgery

Laparoscopic Gastric Sleeve

Adult

26th

2022-HC-304

Home Care

Private Duty Nursing

 Home Care

PDN-2001

Private Duty Nursing

Private Duty Nursing

Adult

26th

2022-RFC-301

Recovery Facility Care

Stroke and Hypertension - Comorbidity Management

Comorbidity Management Guidelines

CMG-024-RF

Multiple Active Conditions

Stroke and Hypertension

Adult

26th

2022-RFC-302

Recovery Facility Care

Inpatient Rehabilitation Facility (Acute Rehabilitation): Major Multiple Trauma

Recovery Facility Care Optimal Recovery Guidelines

 I-7015

Orthopedics

Multiple Trauma

Adult

26th

2022-RFC-303

Recovery Facility Care

Surgical Admission Recovery Facility Care GRG

Recovery Facility Care General Recovery Guidelines

GRG-SUR-RF 

Head and Neck Condition

Complete Laryngectomy 

Adult

26th

2022-RFC-304

Recovery Facility Care

 Septic Arthritis

Optimal Recovery Guidelines > Subacute/Skilled Nursing Facility (SNF) > Infectious Disease

 M-5605

Infectious Disease Condition

Septic Arthritis

Adult

26th

2022-BHC-301

Behavioral Health Care

Major Depressive Disorder, Child or Adolescent: Inpatient Care

Care Guidelines for Behavioral Health Level

B-902-IP 

Behavioral Health -Pediatrics

Major Depressive Disorder 

PEDIATRIC

26th

2022-BHC-302

Behavioral Health Care

Bright Light Therapy

Behavioral Health Care > Therapeutic Services

 B-803-T

Behavioral Health

Major Depression

Adult

26th

2022-BHC-303

Behavioral Health Care

Attention-Deficit and Disruptive Behavior Disorders: Residential Care

Care Guidelines for Behavioral Health > Attention-Deficit and Disruptive Behavior Disorders

 B-003-RES

Behavioral Health -Pediatrics 

Conduct Disorder

PEDIATRIC

26th

2022-BHC-304

Behavioral Health Care

Substance-Related Disorders, Adult: Inpatient Care

Care Guidelines for Behavioral Health > Substance-Related Disorders, Adult

B-015-IP 

Behavioral Health

Alcohol- withdrawal

Adult

26th

2022-BHC-305

Behavioral Health Care

Observation Behavioral Health Level of Care  

Behavioral Health Level of Care Guidelines

 B-906-OBS

Behavioral Health

Alcohol- withdrawal

Adult

26th

2022-BHC-306

Behavioral Health Care

Substance-Related Disorders: Outpatient Care

Care Guidelines for Behavioral Health > Substance-Related Disorders

B-015-AOP

Behavioral Health

Alcohol Misuse

Adult

26th

2023-AC-401

Ambulatory Care

Mosaicplasty

Procedures and Diagnostic Tests > Orthopedics

A-0416

Orthopedics

Degenerative Joint Disease

Adult

26th

2023-AC-402

Ambulatory Care

Augmentative Communication Devices, Electronic

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) > Neurologic Conditions

A-0516

Neurology

Amyotrophic lateral sclerosis (ALS) 

Adult

26th

2023-AC-403

Ambulatory Care

Myeloproliferative Neoplasms - CALR Gene

Genetic Medicine > Oncology

A-0975

Oncology

Primary myelofibrosis

Adult

26th

2023-AC-404

Ambulatory Care

Aquatic Therapy 

Rehabilitation > Therapeutic Modalities

A-0509

Orthopedics

Osteoarthritis

Adult

26th

2023-AC-405

Ambulatory Care

Ixekizumab

Specialty Medications > Autoimmune Conditions

A-0938

Autoimmune Conditions

Plaque psoriasis

Adult

26th

2023-AC-406

Ambulatory Care

Thyroid Radioactive Uptake (Radioactive Iodine Uptake) (RAIU)

Imaging > Nuclear Medicine

A-0085

Nuclear Medicine

Hyperthyroidism

Adult

26th

2023-AC-407

Ambulatory Care

Facet Joint Injection

Procedures and Diagnostic Tests > Neurosurgery

A-0695

Neurosurgery

Arthropathy

Adult

26th

2023-AC-408

Ambulatory Care

Hepatitis C Infection - Referral Management

Referral Management > Gastrointestinal Conditions

R-0043

Gastroenterology

Hepatitis C 

Adult

26th

2023-ISC-401

Inpatient & Surgical Care

Pneumonia: Observation Care

Observation Care Guidelines

OC-030 

Pulmonology

Pneumonia 

Adult

26th

2023-ISC-402

Inpatient & Surgical Care

Vomiting: Observation Care

Observation Care Guidelines

OC-043 

Pediatrics

Vomiting 

PEDIATRIC

26th

2023-ISC-403

Inpatient & Surgical Care

Gallbladder or Bile Duct Inflammation or Stone: Observation Care/Gallbladder or Bile Duct Inflammation or Stone

Observation Care Guidelines/Optimal Recovery Guidelines

OC-055/M-555

Gastroenterology

Cholecystitis/Common Bile Duct Obstruction

Adult

26th

2023-ISC-404

Inpatient & Surgical Care

Pelvic Inflammatory Disease (PID), Acute, Pediatric

Optimal Recovery Guidelines > Pediatric

P-260

Pediatrics

Pelvic Inflammatory Disease 

PEDIATRIC

26th

2023-ISC-405

Inpatient & Surgical Care

Appendectomy, without Abscess or Peritonitis, by Laparoscopy

Optimal Recovery Guidelines > General Surgery

S-175

General Surgery

Appendicitis

Adult

26th

2023-ISC-406

Inpatient & Surgical Care

Meningitis, Bacterial, Pediatric

Optimal Recovery Guidelines > Pediatric

P-220

Pediatrics

Bacterial Meningitis

PEDIATRIC

26th

2023-ISC-407

Inpatient & Surgical Care

Renal Failure, Acute

Optimal Recovery Guidelines > Nephrology

M-326

Nephrology

Acute Renal Failure 

Adult

26th

2023-ISC-408

Inpatient & Surgical Care

Electrophysiologic Study and Intracardiac Catheter Ablation

Optimal Recovery Guidelines > Cardiology

M-154

Cardiology

Atrial Fibrillation 

Adult

26th

2023-RRG-401

Rapid Review Guidelines

Retinal Detachment Repair RRG

Rapid Review Guidelines > Adult > Ophthalmology

S-1030-RRG

Other Condition

Detached Retina: scleral buckling surgery 

Adult

26th

2023-RRG-402

Rapid Review Guidelines

Seizure, Pediatric RRG

Rapid Review Guidelines > Pediatric > Neurology

P-390-RRG

Pediatrics

Seizure 

PEDIATRIC

26th

2023-MCM-401

Multiple Condition Management

Pancreatitis: Observation Care/Pancreatitis with Alcohol Misuse MCM

Observation Care/Multiple Condition Management

OC-065/M-250-AL

Observation Care/ Multiple Condition Management

Gastroenterology 

Adult

26th

2023-GRC-401

General Recovery Care

Thoracic Surgery or Procedure GRG

Body System General Recovery Guidelines

SG-TS

Thoracic Surgery

Thymoma/Thymectomy 

Adult

26th

2023-GRC-402

General Recovery Care

Obstetric and Gynecologic Surgery or Procedure GRG

Body System General Recovery Guidelines

SG-OBS

Gynecology

Rectovaginal fistula closure 

Adult

26th

2023-HC-401

Home Care

Wrist Fracture, Open Treatment

Optimal Recovery Guidelines > Orthopedics

 S-3230

Orthopedics

Wrist fracture 

Adult

26th

2023-HC-402

Home Care

Pneumonia and Dementia - Comorbidity Management

Comorbidity Management Guidelines

CMG-018-H 

Multiple Active Conditions

Pneumonia and Dementia 

Adult

26th

2023-HC-403

Home Care

Neck Dissection

Optimal Recovery Guidelines > Head and Neck Surgery

S-3000

Head and Neck Surgery

Oropharyngeal carcinoma

Adult

26th

2023-HC-404

Home Care

Traumatic Brain Injury, Nonsurgical Treatment, Pediatric 

Optimal Recovery Guidelines > Pediatrics

P-2202

Pediatrics

Traumatic Brain Injury 

PEDIATRIC

26th

2023-RFC-401

Recovery Facility Care

Surgical Admission Recovery Facility Care GRG

Recovery Facility Care General Recovery Guidelines

GRG-SUR-RF 

Urology

Transurethral resection of prostate 

Adult

26th

2023-RFC-402

Recovery Facility Care

Heart Failure and Renal Failure - Comorbidity Management

Comorbidity Management Guidelines 

CMG-010-RF

Comorbidity Management

Heart Failure and Renal Failure

Adult

26th

2023-RFC-403

Recovery Facility Care

Tibia/Fibula Fracture

Optimal Recovery Guidelines > Subacute/Skilled Nursing Facility (SNF) > Orthopedics

S-6124

Orthopedics

Tibia/Fibula Fracture

Adult

26th

2023-RFC-404

Recovery Facility Care

Chronic Obstructive Pulmonary Disease

Optimal Recovery Guidelines > Subacute/Skilled Nursing Facility (SNF) > Thoracic Surgery and Pulmonary Disease

M-5100

Pulmonology

Chronic Obstructive Pulmonary Disease

Adult

26th

2023-BHC-401

Behavioral Health Care

Substance-Related Disorders, Child or Adolescent: Inpatient Care

Care Guidelines for Behavioral Health > Substance-Related Disorders

B-028-IP

Behavioral Health - Pediatrics

Substance-Related Disorders

PEDIATRIC

26th

2023-BHC-402

Behavioral Health Care

Posttraumatic Stress Disorder, Adult: Inpatient Care

Care Guidelines for Behavioral Health > Posttraumatic Stress Disorder

B-013-IP

Behavioral Health

Posttraumatic Stress Disorder

Adult

26th

2023-BHC-403

Behavioral Health Care

Early Psychosis Intervention

Therapeutic Services

B-816-T

Behavioral Health

Schizophrenia spectrum disorder

Adult

26th

2023-BHC-404

Behavioral Health Care

Attention-Deficit and Disruptive Behavior Disorders: Intensive Outpatient Program

Care Guidelines for Behavioral Health > Attention -Deficit and Disruptive Behavior Disorders

B-003-IOP

Behavioral Health - Pediatrics

Disruptive behavior disorder and attention-deficit hyperactivity disorder 

PEDIATRIC

26th

2023-BHC-405

Behavioral Health Care

Persistent Depressive Disorder (Dysthymia): Intensive Outpatient Program

Care Guidelines for Behavioral Health > Persistent Depressive Disorder (Dysthymia)

B-009-IOP

Behavioral Health - Pediatrics

Persistent Depressive Disorder (Dysthymia) 

PEDIATRIC

26th

2023-BHC-406

Behavioral Health Care

Major Depressive Disorder: Residential Care

Care Guidelines for Behavioral Health > Major Depressive Disorder

B-008-RES

Behavioral Health

Major Depression 

Adult