|
|
|
Effective Date |
Archived Date |
||
IV Immune FINAL REVISION |
11/06/01 |
06/01/02 |
|
IV Immune Globin Therapy |
01/08/01 |
11/06/01 |
|
Chest X-ray |
11/13/00 |
11/07/01 |
|
Chest X-ray |
11/08/01 |
04/03/02 |
|
Chest X-ray |
07/24/02 |
01/10/03 |
|
Chest X-Ray |
01/10/03 |
10/01/03 |
|
Chest X-Ray |
10/01/03 |
10/01/04 |
|
Chest X-ray |
10/01/03 |
10/01/04 |
|
Chest X-ray |
10/01/04 |
07/19/05 |
|
Prostate Specific Antigen |
10/26/00 |
01/17/02 |
|
Prostate Specific Antigen FINAL REVISION |
07/24/02 |
01/13/03 |
|
Occupational Therapy |
07/24/02 |
10/01/03 |
|
Occupational Therapy |
10/01/03 |
07/28/04 |
|
Occupational Therapy |
07/20/97 |
11/07/04 |
|
Occupational Therapy |
11/07/04 |
02/17/05 |
|
Hepatitis B |
07/24/02 |
01/13/03 |
|
Hepatitis B |
01/13/03 |
10/01/04 |
|
Blood Glucose Testing |
01/05/01 |
01/18/02 |
|
Blood Glucose Testing |
01/18/02 |
02/08/02 |
|
Blood Glucose Testing |
02/08/02 |
04/02/02 |
|
Blood Glucose Testing |
07/08/02 |
01/14/03 |
|
Blood Glucose Testing |
02/20/97 |
07/22/05 |
|
Patient Education |
01/29/95 |
07/25/05 |
|
Digoxin |
10/26/00 |
01/17/02 |
|
Digoxin FINAL REVISION |
07/24/02 |
01/13/03 |
|
Partial Hospitalization |
07/19/95 |
07/26/05 |
|
Partial Hospitalization |
07/24/02 |
07/19/03 |
|
Thyroid Panel |
03/19/01 |
11/07/01 |
|
Thyroid Panel |
11/08/01 |
01/17/02 |
|
Thyroid Panel |
01/18/02 |
04/02/02 |
|
Thyroid Panel |
07/24/02 |
01/13/03 |
|
Magnesium |
07/24/02 |
01/10/03 |
|
Magnesium |
02/03/03 |
10/01/03 |
|
Magnesium |
10/01/03 |
10/01/04 |
|
Magnesium |
02/20/97 |
07/26/05 |
|
Iron Studies |
03/23/01 |
01/17/02 |
|
Iron Studies FINAL REVISION |
07/24/02 |
01/13/03 |
|
Ifosfamide (Ifex) |
7/24/02 |
11/18/04 |
|
Ifosfamide (Ifex) |
02/20/97 |
07/26/05 |
|
Glycated Protein |
10/26/00 |
01/17/02 |
|
Glycated Protein FINAL REVISION |
07/24/02 |
01/13/03 |
|
Calcium-Ionized |
07/24/02 |
10/01/04 |
|
Calcium - Ionized |
02/20/97 |
07/26/05 |
|
Electrophysiology Studies |
07/24/02 |
10/31/02 |
|
EPS, Electrophysiology Studies |
12/27/96 |
07/26/05 |
|
Lumbosacral Spine X-ray |
07/24/02 |
03/19/04 |
|
Lumbosacral Spine X-ray |
12/27/96 |
07/26/05 |
|
Lumbar Spine MRI |
01/10/01 |
03/23/01 |
|
Lumbar Spine MRI |
03/23/01 |
07/24/02 |
|
Lumbar Spine MRI |
07/24/02 |
01/10/03 |
|
Lumbar Spine MRI |
01/10/03 |
07/24/02 |
|
Lumbar Spine MRI |
12/27/96 |
07/26/05 |
|
Anesthesia for Transvenous Pacemaker Insertion |
12/27/96 |
07/26/05 |
|
Steroid Injections |
07/24/02 |
10/01/04 |
|
Steroid Injections |
10/01/04 |
02/11/05 |
|
Steroid Injections |
12/27/96 |
07/26/05 |
|
Prothrombin Time |
11/07/00 |
01/17/02 |
|
Prothrombin Time FINAL REVISION |
07/24/02 |
01/13/03 |
|
Serum Potassium |
07/24/02 |
01/10/03 |
|
Potassium |
01/10/03 |
10/01/03 |
|
Potassium (Serum) |
10/01/03 |
10/01/04 |
|
Potassium - Serum |
12/27/96 |
07/27/05 |
|
Removal Impacted Cerumen |
12/27/96 |
07/27/05 |
|
Laser Assisted Uvulopalatoplasty |
11/27/96 |
08/03/05 |
|
Impotency Treatment |
11/07/00 |
11/21/01 |
|
Impotency Treatment |
11/22/01 |
04/02/02 |
|
Impotency Treatment |
04/03/02 |
11/22/01 |
|
Impotency Treatment |
07/15/02 |
04/03/02 |
|
Impotency Treatment |
12/27/96 |
08/03/05 |
|
Injectable Iron Preparation |
05/14/03 |
07/19/05 |
|
Injectable Iron Preparation |
07/24/02 |
05/14/03 |
|
Injection, Tendon Sheath, Ligament, Trigger Points |
01/10/01 |
11/26/01 |
|
Injection, Tendon Sheath, Ligament, Trigger Points |
12/27/96 |
08/04/05 |
|
Transthoracic Echocardiography (TTE) |
07/24/02 |
01/10/03 |
|
Transthoracic Echocardiography (TTE) |
01/10/03 |
12/05/03 |
|
Transthoracic Echocardiography (TTE) |
12/27/96 |
08/03/05 |
|
Pelvic Echography for Prostate Follow-up |
12/27/96 |
08/03/05 |
|
Pulmonary Perfusion Imaging |
12/27/96 |
08/05/05 |
|
Psychiatry and Psychology Services |
04/28/00 |
05/11/00 |
|
Psychiatry and Psychology Services |
05/12/00 |
11/27/01 |
|
Psychiatry and Psychology Services |
11/28/01 |
04/02/02 |
|
Psychiatry and Psychology Services |
07/24/02 |
11/15/04 |
|
Psychiatry and Psychology Services |
12/27/96 |
08/05/05 |
|
Flow Cytometry |
07/24/02 |
12/06/05 |
|
Noninvasive Vascular Studies |
07/24/02 |
01/10/03 |
|
Noninvasive Vascular Studies |
01/10/03 |
07/10/03 |
|
Noninvasive Vascular Studies |
07/10/03 |
07/24/03 |
|
Noninvasive Vascular Studies |
07/24/03 |
12/06/05 |
|
Indocyanine Green Angiography |
07/24/02 |
07/10/03 |
|
Indocyanine Green Angiography |
07/10/03 |
12/06/05 |
|
Indocyanine Green Angiography |
12/07/05 |
09/01/08 |
|
Transrectal Echography for Prostatic Disease |
07/24/02 |
11/16/04 |
|
Removal of Benign Skin Lesions |
12/27/96 |
11/16/04 |
|
Colonoscopy |
07/23/02 |
11/06/02 |
|
Colonoscopy |
11/07/02 |
12/06/05 |
|
Interventional Cardiology |
07/24/02 |
12/06/05 |
|
Interventional Cardiology |
12/07/05 |
09/01/08 |
|
Botulinum Toxin Type A |
07/24/02 |
03/27/05 |
|
Botulinum Toxin Type A |
03/29/05 |
12/06/05 |
|
Percutaneous Transluminal Angioplasty in Renal Dis |
07/24/02 |
01/19/05 |
|
Percutaneous Transluminal Angioplasty in Renal Dis |
01/19/05 |
03/01/05 |
|
Percutaneous Transluminal Angioplasty in Renal Dis |
03/01/05 |
12/06/05 |
|
Percutaneous Transluminal Angioplasty in Renal Dis |
12/07/05 |
09/01/08 |
|
Diagnostic Mammogram |
11/08/00 |
11/08/01 |
|
Diagnostic Mammogram |
11/08/01 |
11/28/01 |
|
Diagnostic Mammogram |
11/28/01 |
04/02/02 |
|
Diagnostic Mammogram |
07/22/02 |
01/10/03 |
|
Diagnostic Mammogram |
01/10/03 |
10/01/03 |
|
Diagnostic Mammogram |
10/01/03 |
02/11/05 |
|
Diagnostic Mammogram |
02/11/05 |
12/06/05 |
|
Occult Blood, Feces Testing |
11/13/00 |
11/07/01 |
|
Occult Blood, Feces Testing |
11/08/01 |
01/17/02 |
|
Occult Blood, Feces Testing |
01/18/02 |
04/01/02 |
|
Occult Blood - Feces |
01/17/03 |
12/06/05 |
|
Leuprolide/Goserelin |
07/24/02 |
03/31/05 |
|
Leuprolide/Goserelin |
03/31/05 |
12/06/05 |
|
Barium Swallow (Video/Cine) |
07/24/02 |
12/06/05 |
|
Bacterial Culture |
01/29/05 |
09/18/05 |
|
Bacterial Culture |
01/05/01 |
11/20/01 |
|
Bacterial Culture |
10/19/97 |
10/01/04 |
|
Bacterial Culture |
10/01/04 |
02/14/05 |
|
Prostatic Acid Phosphatase (PAP) |
07/24/02 |
01/10/03 |
|
Prostatic Acid Phosphatase (PAP) |
01/10/03 |
12/07/05 |
|
Prostatic Acid Phosphatase (PAP) |
12/08/05 |
09/01/08 |
|
Leuprolide/Goserelin |
12/07/05 |
09/01/08 |
|
Syphilis Test |
07/24/02 |
01/10/03 |
|
Syphilis Test |
01/10/03 |
12/07/05 |
|
Syphilis Test |
12/08/05 |
09/01/08 |
|
Rheumatoid Factor Test |
07/24/02 |
01/10/03 |
|
Rheumatoid Factor Test |
01/10/03 |
08/05/03 |
|
Rheumatoid Factor Test |
08/05/03 |
12/07/05 |
|
Theumatoid Factor Test |
12/08/05 |
09/01/08 |
|
Bacterial Culture, Urine |
12/22/00 |
01/17/02 |
|
Bacterial Culture, Urine FINAL REVISION |
07/24/02 |
01/13/03 |
|
Measurement of Bone Density |
02/23/01 |
12/06/01 |
|
Measurement of Bone Density |
07/24/02 |
01/09/03 |
|
Bone Density Measurement |
01/09/03 |
07/17/03 |
|
Bone Denisty Measurement |
07/17/03 |
10/01/03 |
|
Bone Density Measurement |
10/01/03 |
10/01/04 |
|
Bone Density Measurement |
01/01/98 |
11/09/04 |
|
Bone Density Measurement |
11/07/04 |
12/07/05 |
|
Physical Therapy |
07/24/02 |
06/19/03 |
|
Physical Therapy |
06/19/03 |
10/01/03 |
|
Physical Therapy |
10/01/03 |
10/01/04 |
|
Physical Therapy |
01/01/98 |
10/28/04 |
|
Physical Therapy |
10/01/04 |
11/10/04 |
|
Physical Therapy |
01/01/98 |
02/01/05 |
|
Electrocardiogram |
01/09/01 |
03/14/01 |
|
Electrocardiogram |
07/24/02 |
10/31/02 |
|
Electrocardiogram |
10/31/02 |
10/01/03 |
|
Electrocardiogram |
10/01/03 |
10/01/04 |
|
Electrocardiogram |
10/01/04 |
12/07/05 |
|
PRN Orders for Skilled Nursing Facilities |
07/24/02 |
12/07/05 |
|
PRN Orders for Skilled Nursing Facilities |
12/08/05 |
09/01/08 |
|
Observation Room Services FINAL REVISION |
02/23/01 |
06/01/02 |
|
Speech Therapy |
07/24/02 |
07/19/03 |
|
Speech Therapy |
07/19/03 |
12/17/04 |
|
Speech Therapy |
01/01/04 |
02/17/05 |
|
Respiratory Therapy |
07/24/02 |
10/01/04 |
|
Respiratory Therapy |
10/01/04 |
11/07/04 |
|
Respiratory Therapy |
11/07/04 |
03/08/05 |
|
Urinalysis |
06/28/00 |
03/20/01 |
|
Urinalysis |
03/20/01 |
07/24/02 |
|
Urinalysis |
07/24/02 |
01/09/03 |
|
Urinalysis |
01/09/03 |
05/14/03 |
|
Urinalysis |
05/14/03 |
10/01/03 |
|
Urinalysis |
10/01/03 |
10/01/04 |
|
Urinalysis |
10/01/04 |
12/07/05 |
|
Urinalysis |
12/08/05 |
09/01/08 |
|
Cardiac Catheterization |
07/24/02 |
10/30/02 |
|
Cardiac Catheterization |
10/30/02 |
01/09/03 |
|
Cardiac Catheterization |
01/09/03 |
02/11/05 |
|
Cardiac Catheterization |
01/20/05 |
12/07/05 |
|
Lipid Profile |
02/26/01 |
01/17/02 |
|
Lipid Profile FINAL REVISION |
07/24/02 |
01/13/03 |
|
HIV Testing (Diagnosis) |
01/05/01 |
01/17/02 |
|
HIV Testing (Diagnostic) FINAL REVISION |
07/24/02 |
01/13/03 |
|
Blood Count (CBC) |
02/26/01 |
01/17/02 |
|
Blood Count (CBC) FINAL REVISION |
07/24/02 |
01/13/03 |
|
CEA Carcinoembryonic Antigen |
02/26/01 |
01/17/02 |
|
CEA Carcinoembryonic Antigen FINAL REVISION |
07/24/02 |
01/13/03 |
|
Bladder Tumor Antigen |
02/26/01 |
01/25/02 |
|
Bladder Tumor Antigen |
07/24/02 |
01/09/03 |
|
Bladder Tumor Antigen |
01/09/03 |
12/07/05 |
|
Alpha-fetoprotein (APT) Tumor Antigen |
02/27/01 |
01/17/02 |
|
Alpha-fetoprotein Tumor Antigen FINAL REVISION |
07/24/02 |
01/13/03 |
|
CA125 Tumor Antigen |
02/27/01 |
01/17/02 |
|
CA125 Tumor Antigen FINAL REVISION |
07/24/02 |
01/13/03 |
|
CA15-CA27.29 Tumor Antigen |
02/27/01 |
01/17/02 |
|
CA15-CA27.29 Tumor Antigen FINAL REVISION |
07/24/02 |
01/13/03 |
|
CA19-9 Tumor Antigen |
02/27/01 |
01/17/02 |
|
Ca 19-9 Tumor Antigen FINAL REVISION |
01/18/02 |
01/13/03 |
|
hCG, Human Chorionic Gonadotropin Qualitative |
03/23/01 |
01/17/02 |
|
HCG-Human Chorionic Gonadadotropin |
01/17/03 |
10/01/04 |
|
HCG, Human Chorionic Gonadotropin Qualitative |
10/01/04 |
12/07/05 |
|
Blepharoplasty |
07/24/02 |
10/31/02 |
|
Blepharoplasty |
10/31/02 |
12/13/05 |
|
Psychiatric Services-Outpatient Hospital based |
09/28/00 |
11/10/04 |
|
Psychiatric Services - Outpatient Hospital Based |
09/28/00 |
12/15/05 |
|
Self-administered Injectable Drugs FINAL REVISION |
08/01/02 |
09/24/02 |
|
Troponin |
07/24/02 |
12/13/05 |
|
Electrocardiographic Monitoring for 24 hours |
07/24/02 |
12/13/05 |
|
Pulmonary Rehabilitation |
03/11/03 |
06/10/03 |
|
Pulmonary Rehabilitation |
06/10/03 |
10/01/03 |
|
Pulmonary Rehabilitation |
10/01/03 |
12/05/03 |
|
Acute Care: Inpatient, Observation and Treatment R |
06/01/02 |
11/09/04 |
|
Acute Care: Inpatient, Observation & Treatment Rm |
06/01/02 |
01/16/03 |
|
Acute Care: Inpatient, Observation, Treatment Room |
01/16/03 |
07/17/03 |
|
Acute Care: Inpatient, Observation, Treatment Room |
11/07/04 |
09/08/05 |
|
Acute Care: Inpatient, Observation, Treatment Room |
09/08/05 |
12/30/05 |
|
IVIG (Intravenous Immunoglobulin) |
06/01/02 |
06/24/02 |
|
IVIG (Intravenous Immunoglobulin) |
06/24/02 |
07/03/02 |
|
IVIG (Intravenous Immunoglobulin) |
07/03/02 |
08/01/02 |
|
IVIG (Intravenous Immunoglobulin) |
08/01/02 |
01/08/03 |
|
IVIG (Intravenous Immunoglobulin) |
01/08/03 |
03/26/03 |
|
IVIG (Intravenous Immunoglobulin) |
03/26/03 |
10/01/03 |
|
Intravenous Immunoglobulin |
06/01/04 |
11/09/04 |
|
Intravenous Immunoglobulin |
11/07/04 |
04/20/05 |
|
IVIG, Intravenous Immunoglobulin |
04/01/05 |
02/23/06 |
|
Ground Ambulance |
06/01/02 |
07/22/02 |
|
Ground Ambulance |
07/22/02 |
08/01/02 |
|
Ground Ambulance |
08/01/02 |
01/23/03 |
|
Ground Ambulance |
01/23/03 |
02/03/03 |
|
Ground Ambulance |
02/03/03 |
10/01/03 |
|
Ground Ambulance Services |
10/01/05 |
02/11/05 |
|
Ground Ambulance |
01/29/05 |
12/31/05 |
|
Rural Health Clinic |
12/27/02 |
08/31/05 |
|
Rural Health Clinic |
08/31/05 |
12/28/05 |
|
Wireless Capsule Endoscopy |
09/29/02 |
12/13/05 |
|
Percutaneous Vertebroplasty |
09/29/02 |
12/13/05 |
|
Kyphoplasty |
09/29/02 |
11/06/02 |
|
Kyphoplasty |
11/06/02 |
02/17/05 |
|
Kyphoplasty |
09/29/02 |
12/15/05 |
|
Human Skin Equivalent |
12/18/02 |
02/11/05 |
|
Human Skin Equivalent |
01/29/05 |
12/16/05 |
|
Infliximab |
09/29/02 |
03/25/03 |
|
Infliximab |
03/25/03 |
08/10/04 |
|
Infliximab |
03/25/03 |
03/01/05 |
|
Infliximab |
09/29/02 |
12/13/05 |
|
Epoetin Alfa (Epogen, EPO, Erythropoetin) |
09/29/02 |
10/31/02 |
|
Epoetin Alfa (Epogen, EPO, Erythropoietin) |
10/31/02 |
02/??/04 |
|
Epoetin Alfa (Epogen, EPO, Erythropoietin) |
09/29/02 |
12/15/05 |
|
Erythropoietin Analogs (Aranesp, Darbepoetin) |
01/17/03 |
10/04/04 |
|
Erythropoietin Analogs |
09/29/02 |
12/14/05 |
|
Off-Label Coverage of FDA Approved |
09/30/04 |
11/07/04 |
|
Off-Label Coverage of FDA Approved Drugs and Biolo |
11/07/04 |
02/11/05 |
|
Off-Label Coverage of FDA Approved Drugs and Bio |
09/30/03 |
12/16/05 |
|
Mohs Micrographic Surgery |
09/30/03 |
12/08/05 |
|
Intensity Modulated Radiation Therapy (IMRT) |
09/30/03 |
11/11/04 |
|
Intensity Modulated Radiation Therapy (IMRT) |
11/07/04 |