UM Guidelines

- A -

Ambulatory Surgery Complications: Observation Care

Assertive Community Treatment (ACT)/Program of Assertive Community Treatment (PACT)

- B -

Bone Excision

Breast Cancer - PALB2 Gene

Breast or Ovarian Cancer, Hereditary - BRCA1 and BRCA2 Genes (Sequence Analysis and Common Duplication or Deletion Variants)

- C -

Cardioverter-Defibrillator Insertion

Carotid Endarterectomy

Cesarean Birth

Cognitive Communication Disorders Rehabilitation

Community Intensive Interventions for Families (CIIF) - Intensive Outpatient Program - For BlueCare Use Only

Community-Based Enhanced Supported Housing: Behavioral Health - For BlueCare Use Only

Community-Based Medically Fragile Supported Housing: Behavioral Health - For BlueCare Use Only

Community-Based Routine Supported Housing: Behavioral Health - For BlueCare Use Only

Community-Based Specialized Supported Housing: Behavioral Health - For BlueCare Use Only

Comprehensive Child and Family Treatment (CCFT): Intensive Outpatient Program

Continuous Positive Airway Pressure (CPAP) Device

Continuous Treatment Team (CTT): Intensive Outpatient Program

Cystic Fibrosis - CFTR Gene and Mutation Panel

- D -

- E -

Evaluation / Assessment for Applied Behavior Analysis

Evaluation / Assessment for Applied Behavior Analysis - For BlueCare Use Only

- F -

Foot Orthotics, Custom

- G -

Gastric Restrictive Procedure with Gastric Bypass

Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy

Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy

Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy

Gynecologic Surgery by Laparotomy

- H -

Home Phototherapy Device for Neonatal Hyperbilirubinemia

Hospice Care

Hyperemesis Gravidarum - Case Management

- I -

Intensive Interventions for Families (IFF) - For BlueCare Use Only

- J -

- K -

- L -

Laminectomy with Rhizotomy

Liver Transplant

Liver Transplant, Pediatric

- M -

Mastectomy, Complete

Mastectomy, Complete, with Insertion of Breast Prosthesis or Tissue Expander

Mastectomy, Complete, with Tissue Flap Reconstruction

Medical Nutrition Therapy for Dietary Counseling

- N -

- O -

Other Psychiatric Disorders: Intensive Outpatient Program

Other Psychiatric Disorders: Residential Care

- P -

Polysomnography (PSG), Sleep Center

Prostate Cancer - BRCA1 and BRCA2 Genes

Psychosocial Rehabilitation - For BlueCare Use Only

- Q -

- R -

Respite Care, Adult: Residential Care

Respite Care, Child/Adolescent: Residential Care

- S -

Sclerotherapy, Leg Veins

Skilled Nursing Facility/Inpatient Rehabilitation Fax Form

Skilled Nursing Facility (SNF) Levels of Care

Skilled Nursing Facility Admission for Enhanced Respiratory Care - Ventilator Weaning - For BlueCare Use Only

Smoking Cessation

Specialized Comprehensive Child and Family Treatment (SCCFT): Intensive Outpatient Program - For BlueCare Use Only

Specialized Comprehensive Treatment Team (SCTT): Intensive Outpatient Program - For BlueCare Use Only

Stereotactic Radiosurgery

Sub-Acute Behavioral Health Level of Care, Adult: Partial Hospital Program

Substance-Related Disorders, Adult: Inpatient Care

Substance-Related Disorders, Child or Adolescent: Inpatient Care

- T -

Tennessee Health Link Guidelines: Adults - For BlueCare and TennCare Select Use Only

Tennessee Health Link Guidelines: Children and Adolescents - For BlueCare and TennCare Select Use Only

Thoracic Surgery & Pulmonary Disease Intensive Care Admission

Thoracotomy with Biopsy or Miscellaneous Procedures by Video-Assisted Thoracic Surgery (VATS)

- U -

- V -

Vaginal Birth

Vaginal Birth - Operative

- W -- X - Y - Z -