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Centers for Medicare

... quality of life; or Decision Memo for Positron Emission Tomography (NaF ... Several commenters suggested that the medical evidence supported broader coverage of NaF-18 PET ...

http://www.snm.org/docs/NaF18.pdf

SNM Guideline for Sodium

demonstrate medical necessity, and should ... positron-emission tomography/computed tomography on ... PET/CT imaging: Is there a clinical future? (letter) J Nucl Med 2010 51(1 ...

http://interactive.snm.org/docs/Practice%20Guideline%20NaF%20PET%20V1.1.pdf

Sample Letter of Medical Necessity

Sample Letter of Medical Necessity Date Insurer Name Insurer Address City, State, Zip Code Re: Patients Name Policy Number Group Number Date of Birth

http://www.apligraf.com/professional/pdf/Sample_Letter_of_Medical_Necessity.pdf

The Federal FSA Program

The Federal FSA Program FSAFEDS Program PO Box 36880 Louisville, KY 40233 www.FSAFEDS.com Rev. 07.11 The Federal FSA Program . Letter of Medical Necessity (LMN)

https://www.fsafeds.com/forms/MedicalNecessity.pdf

SAMPLE LETTER PRE-AUTHORIZATION AND MEDICAL NECESSITY FOR

SAMPLE LETTER PRE-AUTHORIZATION AND MEDICAL NECESSITY FOR X-STOP Interspinous Process Decompression (IPD ) Procedure Name of Medical Director or Medical Reviewer

http://www.kyphon.com/pdfs/XSTOP_MedNecessity_110207.pdf

Volume 11.3 The newsletter for Medical Office and Facility Staff ...

letter, weve included a form that can be ... Abdomen 74185 Neck 70547 70548 70549 Positron Emission Tomography ... medical necessity, the Plan will assign it a ...

https://www.excellusbcbs.com/download/files/just_the_facts_mar_2005_cny.pdf

PET/CT Request Form and Letter of Medical Necessity

Breast Cancer Non-Small Cell Lung CancerCervical Cancer Colorectal Cancer Esophageal Cancer Head Neck Cancer Lymphoma Medicare PET Registry (NOPR)

http://www.swedish.org/Media-Files/Documents/Cancer/NewPatient/PET-CTReferrlaForm

Appeal that Claim

Appeal letter medical necessity denialOption A AMA members can download an interactive copy of this letter to use in their practices. Sample appeal letter medical ...

http://www.ama-assn.org/resources/doc/psa/appeal-that-claim.pdf

To Be Filled Out By Referring Physician

Doctors Name (Printed) Doctors Phone Number Doctors Address Letter of Medical Necessity/Referral Speech Therapy Treatment and Evaluation

http://www.otawatertown.com/images/getting%20started/letter%20of%20medical%20necessity%20form%20speech%20rev.pdf

The National Oncologic PET Registry (NOPR): B. Operations Manual ...

PET refers to positron emission tomography that is ... A copy of this approval letter is included in Appendix B-III). Individual PET ... to receive your usual medical ...

http://www.cancerpetregistry.org/pdf/NOPR%20web%20site%20section%20b_02011.pdf

Volume 11.3 The newsletter for Medical Office and Facility Staff ...

letter, weve included a form that can be ... Abdomen 74185 Neck 70547 70548 70549 Positron Emission Tomography ... medical necessity, the Plan will assign it a ...

https://www.excellusbcbs.com/download/files/just_the_facts_mar_2005_cny.pdf

PET/CT Request Form and Letter of Medical Necessity

Breast Cancer Non-Small Cell Lung CancerCervical Cancer Colorectal Cancer Esophageal Cancer Head Neck Cancer Lymphoma Medicare PET Registry (NOPR)

http://www.swedish.org/Media-Files/Documents/Cancer/NewPatient/PET-CTReferrlaForm

PRIOR AUTHORIZATION REQUEST DIAGNOSTIC IMAGING

Foundation for Medical Care (CFMC) at 303-790-4643: Letter of Medical Necessity ... BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION EVALUATION

http://www.colorado.gov/cs/Satellite?blobcol=urldatablobheader=application%2Fpdfblobkey=idblobtable=MungoBlobsblobwhere=1239166314516ssbinary=true

The National Oncologic PET Registry (NOPR):

PET refers to positron emission tomography that is usually integrated ... A copy of this approval letter is included in ... well-supported by available scientific and medical ...

http://www.cancerpetregistry.org/pdf/NOPR%20web%20site%20section%20b_02011.pdf

Services for which predeterminations can be requested

... medical record documentation and may include: Letter of Medical Necessity ... 5 PET Scan - Follow AIM guideline if applicable Positron emission tomography (PET) or ...

http://www.bcbsil.com/provider/pdf/predetermination_policies.pdf

Letter of Medical Necessity

Revised101010 Flex-Plan Services Letter of Medical Necessity Certain medical expenses are not reimbursable under a Health Care Flexible Spending Arrangement

http://www.flex-plan.com/pdf/mednecessity.pdf

MBA, CNMT, FSNMTS,CPC Coding Billing Optimizing Your Practice NM

necessity to Not Otherwise Classified ... todays medical terminology and is understood by ... PI (eye)Positron emission tomography (PET) or PET/computed tomography ...

http://www.swcsnm.org/meetings/2011Presentations/fridaypres/07_Merlino.pdf

THIS IS NOT AN APPEAL FORM AND CANNOT BE USED FOR VERIFICATION

PET Scan Synagis Transplants Mail to the Following Address or Fax to: BCBSOK ... to facilitate your request, for example, the history physical, letter of medical necessity ...

http://www.bcbsok.com/pdf/predetermination_request_form.pdf

Instructions for Imaging Prior Authorization (PAR)

Attach supporting documentation including but not limited to: Letter of Medical Necessity Other 7. Instructions: All non-emergent CT, non-emergent MRI and all PET scans ...

http://www.colorado.gov/cs/Satellite?blobcol=urldatablobheader=application%2Fpdfblobkey=idblobtable=MungoBlobsblobwhere=1239166314516ssbinary=true

Letter of Medical Necessity

Revised101010 . Flex-Plan Services . Letter of Medical Necessity . Certain medical expenses are not reimbursable under a Health Care Flexible Spending Arrangement

http://www.flex-plan.com/pdf/mednecessity.pdf

PET Medical Necessity Form 072409

UNIVERSITY OF KANSAS PET MEDICAL NECESSITY FORM PHYSICIAN APPROVAL _____ FAX to (913) 588-0235 (Radiology) and (913) 945-5637 (Cancer Center Pre-Cert ...

http://www.rad.kumc.edu/nucmed/pet/PET_Medical_Necessity_Form_072409.pdf

Re: Reminder Notice for Predetermination of Benefit Services

This process* reviews the medical necessity of tests and ... System - OATS procedures Panniculectomy PET ... The list in the letter does not include a test my ...

http://www.bcbsil.com/exelon/pdf/predetermination_correspondence.pdf

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