For Members

• What are Herbal Supplements?
  • Herbal supplements are products derived from plants and/or their oils, roots, seeds, berries or flowers. Herbal supplements have been used for many centuries.
  • If you are considering using an herbal supplement, please be aware that many herbal supplements may interact with both prescription and nonprescription medications and can cause some very serious interactions and adverse effects.
  • If you have allergies, especially allergies to plants, weeds, or pollen, you should consult your primary health care provider before taking herbal supplements. Patients taking blood thinners should always consult their primary health care provider before using any of the herbal supplements/medications.
  • Remember, “natural” does not always mean safe and free of adverse effects. When it comes to your health, always discuss with your treating physician when in doubt.
• Insurance coverage of Herbal Supplements/Medications:
  • Herbal medicines are covered by NEXtCARE only if mentioned/covered explicitly in the table of benefits, except for a specific list which is covered based on the medical necessity.

For Healthcare Providers

• All types of herbal preparations require Pre-Authorization from NEXtCARE.
• In case of rejection, the reasons for herbal supplements/medicines will be:
  • M009: Prescribed medicines not covered as per policy
  • NCOV-003: Service(s) is (are) not covered
  • NCOV-027: Non Coverage of certain medication as per policy

For Members

• What are multivitamins?
  • Multivitamins are a combination of many different vitamins that are normally found in foods and other natural sources.
  • Multivitamins are used to treat vitamin deficiencies (lack of vitamins) caused by illness, pregnancy, poor nutrition, digestive disorders, and many other conditions.
  • Most of the people do not require Multivitamins because a healthy balanced diet provides all essential vitamins. However, if vitamins that are not taken in through the diet and results in deficiency, those can be provided through Multivitamins.
  • Long term usage of Multivitamins might have serious side effects because certain minerals contained in a multivitamin can result into serious overdose symptoms. Seek emergency medical attention if you think that you have used too much of multivitamins. An overdose of vitamins A, D, E, or K can cause severe or life-threatening situations.
  • Always discuss with your treating Physician before using Multivitamins, especially if you are pregnant or breastfeeding.
• Insurance Coverage of multivitamins:
  • Coverage of multivitamins by insurance varies according to the table of benefits, some policies are covering multivitamins only when prescribed with antibiotics.
  • NEXtCARE is covering multivitamins if covered by policy terms and conditions in cases of Increased requirements for nutrients due to medical condition, such as celiac disease, cancer, cystic fibrosis, or inflammatory bowel disease (IBD), surgery that impacts the intestines or stomach.
  • NEXtCARE is not covering multivitamins that are result of general dietary deficiencies.

For Healthcare Providers

• All types of multivitamins require Pre-Authorization from NEXtCARE.
• multivitamins that are results from general dietary deficiencies are not covered.
• Requests for vitamins or multivitamins should be sent along with clear medical indications or laboratory test results.
• In case of multivitamins rejection, the rejection reason will be:
  • M010: Vitamins/supplements are not covered
  • NCOV-003: Service(s) is (are) not covered
  • NCOV-027: Non Coverage of certain medication as per policy
  • MNEC-007: Service is not clinically indicated based on good clinical practice, without additional supporting documentation
  • MNEC-004 Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities

For Members:

Dietary supplements come in various forms, such as tablets, gummies, capsules, powders, liquids, and energy bars. And they include natural ingredients as vitamins, minerals, herbs, amino acids, and enzymes. These supplements can help you achieve a balance between the foods and nutrients you personally need, but they cannot replace the food. Excessive amounts of supplements can be bad for your health, even if they are considered “natural”. So, consult your healthcare provider before taking them. Dietary supplements are covered by NEXtCARE only if mentioned explicitly in the table of benefits, below are Examples of Dietary supplements:

• Multivitamins labeled as Food or Dietary Supplements,
• Multivitamins that are not used in the pregnancy or for treating known vitamin
• deficiency,
• Collagen,
• Glucosamine,
• Thioctic acid,
• Co-Enzyme 10,
• Fish oils

Why are dietary supplements not covered by insurance?
There are many reasons that the insurance companies are not covering the dietary supplement below are some

• Dietary supplements are not used for the purpose of treating, diagnosing, or curing
• Many supplements contain active ingredients that have strong biological effects on
• the body. This makes them unsafe in some situations and might not have positive
• impact on your health.
• Most individuals are abusing and misusing dietary supplements for various reasons
• or Dietary supplements can be misused.
• Unlike medications, Dietary supplements can be replaced by a healthful diet.

What to do if your insurance policy does not cover dietary supplements?

• Eat healthy foods as it is the best way to get all the required nutrients.
• If you do take dietary supplements, always read the safety label that is included in the packaging.
• Ask your healthcare provider if the supplement you’re considering would be safe and beneficial for you.
• Keep in mind that even if your doctor prescribes a certain dietary supplement, your insurance might not cover it as per your policy terms and conditions.

For Healthcare Providers:

When prescribing a dietary supplement please always inform the member about the policy exclusions, because most of the insurance plans are not covering it. If the policy is not covering dietary supplement, the below rejection reason will be received: The rejection reason mapped to M009: The rejection reason mapped to this denial is NCOV-003: Service(s) is (are) not covered.

For Members:

• What is Proton pump inhibitors?

Proton pump inhibitors (PPIs) and histamine H2 antagonists (H2 blockers) are the most common medications prescribed for the treatment of gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD). The treatment usually begins with antacids or over-the-counter H2 blockers for mild symptoms.

• Which is better PPI or h2 blocker?

Both medications work by blocking and decreasing the production of stomach acid, but PPIs are considered stronger and faster in reducing stomach acids. However, H2 receptor blockers specifically decrease the acid released in the evening, which is a common contributor to peptic ulcers.

• What are the symptoms of too much acid in your stomach?
  • Abdominal discomfort, which may be worse on an empty stomach.
  • nausea or vomiting.
  • bloating.
  • heartburn.
  • diarrhea.
  • decreased appetite.
  • unexplained weight loss.

• How can I reduce my stomach acid naturally?
  • Eat sparingly and slowly. When the stomach is very full, there can be more reflux into the esophagus. It is advised to consume small meals.
  • Avoid certain foods, e.g. Spicy or Oily food
  • Don’t drink carbonated beverages, especially on an empty stomach.
  • Stay up after eating, wait for 2 to 3 hours before lying down.
  • Don’t move too fast or exercise after eating.
  • Sleep on an incline. Use extra pillows or place blocks under the head of your bed to raise it at least 4 inches to 6 inches.
  • Lose weight if it is advised, with diet modification and exercise.
  • If you smoke, quit.
  • Avoid wearing tight clothes or tight belts.
  • Reduce or avoid caffeine intake.

For Healthcare Providers:

Recommendations:

• ICD codes must be coded to the highest level of specificity.
• Claims for PPI and H2 Antagonist are subject to rejection if non of the below ICDs are used and shall be marked as “Drug is not indicated to the condition/s for which it was prescribed”

References:

• https://www.webmd.com/heartburn-gerd/guide/what-is-acid-reflux-disease#3
• https://www.nice.org.uk/guidance/cg184/ifp/chapter/heartburn-and-reflux

For Members

What is COVID-19?
Corona Virus Infectious Disease, first incident happened in 2019 is called, COVID-19.

• CO is for Corona
• V is for Virus
• ID is for Infectious Disease
• 19 is for 2019.

What are the symptoms of COVID-19?
Most common symptoms: Fever, Dry Cough, Tiredness/Fatigue, and Loss of sense of taste & smell. However, serious symptoms include: Difficulty of breathing or severe shortness of breath, chest pain or pressure, loss of speech or movement.

What should I do if I have symptoms in UAE?
It’s very important to start isolating yourself and visit the nearest network healthcare provider to check if it’s necessary to do the PCR test.

Does my insurance cover COVID-19 test?

• Dubai Policies:
  • If you are having symptoms, and you have a DHA insurance policy(Dubai policy), then your policy will cover medically required services requested by the treating physician.
  • If you are asymptomatic or came in contact with COVID-19 positive case, your policy will not cover the screening test for COVID-19.
  • For insurance policies other than DHA, your healthcare provider shall advise you if it will be covered or not according to the rules and regulations of each emirate.
• Abu Dhabi Policies:
  • Diagnostic and Treatment Services are covered under Program No. (5) of the Activity-Based Funded Mandates which includes epidemics and pandemics for all providers located in the Emirate of Abu Dhabi only.
  • Cost of diagnosis/treatment of COVID-19 cases for DOH compliant policies (Abu Dhabi and Al Ain) incurred in facilities outside the Emirate of Abu Dhabi shall be subject to the policy terms and condition, and might be rejected unless specified by the payer/insurer as a general rule.
• Northern Emirates (Non-DHA & Non-DOH Policies):
  • If your Policy is not regulated by DHA or DOH, please contact the payer/insurer because coverage will depend on their decision.

Am I covered for COVID-19 test and treatment outside UAE?

COVID-19 tests and treatment undergone abroad are not part of your UAE health insurance coverage.

Who do I call if I need more information?

• Ministry of Health & Prevention – call 80011111
• Abu Dhabi: Department of Health – Estijaba service – call 8001717
• Dubai: Dubai Health Authority – call 800342

For Healthcare Providers

• Signs and symptoms: For patients presenting with any signs/symptoms and where a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms such as:
• Cough (786.2)
• Shortness of breath (786.05)
• Fever unspecified (780.6)
• Immunoassay for infectious agent antibody/ies (86328) [qualitative or semi quantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARSCoV-2)].
• PCR test: Infectious agent detection by nucleic acid, DNA or RNA please use CPT 87635.
• Please follow the local regulators coding guidelines for preapproval/claim submission of COVID-19 related claims.
• For the purpose of mapping new mandatory COVID-19 procedure prices for the existing CPT codes, twelve new DSL codes was introduced by the DHA, these have been created to ease the operations of all providers and payers without changing already agreed and existing pricing for the services listed below to be inline with standard unified pricing stated in GC 13 of 2020
• To report confirmed cases, assign code U07.1 “COVID-19” then followed by the specific respiratory condition (e.g. pneumonia, acute bronchitis or unspecified acute lower respiratory infection etc.). Only assign signs and symptoms codes where a definitive diagnosis has not be established.
• To report suspected cases, assign Z20.828 “Contact with and exposure to other viral communicable diseases”.
• To report negative cases, assign Z03.818 “Encounter for observation for suspected exposure to other biological agents ruled out”.
• To report screening for asymptomatic cases, assign Z11.59 “Encounter for screening for other viral diseases”.
• To report asymptomatic cases with positive test result, assign U07.1 “COVID-19”.
• To report infection during pregnancy, childbirth or the puerperium, assign O98.5x, Other viral diseases complicating pregnancy, childbirth and the puerperium then followed by U07.1 “COVID-19”.

For Members

What is circumcision?

Circumcision refers to the removal of the foreskin, or prepuce that covers the glans penis (head of the penis).

Baby Vs Adult Circumcision
Circumcision surgery on male babies is fairly straightforward and commonplace. It is usually done for religious, medical or personal-choice reasons. However, the procedure in adults is less frequent, and more complicated in terms of surgical accuracy and skill required to achieve optimal patient results. Recovery time varies according to the age and general health of the person. A baby or child will generally heal in five to seven days after the procedure, while in adults, recovery can take around two to three weeks. If the circumcision is performed during the newborn period, it will take only about five to 10 minutes and it is performed under local anesthesia. For adults, it usually takes an hour approximately and it is performed under general anesthesia.

What are the indications for male circumcision?

• Elective circumcision in adults can be performed for religious, cosmetic or personal reasons and is subject to prior approval from your insurer.
• Male circumcision is considered medically necessary when the individual has any of the following conditions:
  • Preputial neoplasms; or
  • Recurrent balanitis; or
  • Recurrent balanoposthitis; or
  • Symptomatic phimosis; or
  • Paraphimosis; or
  • Tears of the frenulum; or
  • Trauma to the foreskin requiring surgical treatment.

Does my insurance cover Circumcision?

Coverage of Circumcision varies with different insurance policies and different local regulations: For Dubai based policy (DHA), medical necessary circumcision is covered for members upto 2 years old or below and will require prior approval. For Abu Dhabi based policy (DOH), circumcision is not covered. For Northern emirates, coverage of circumcisionvaries according to the table of benefit for each policy, please always all NEXtCARE to check if circumcision is covered.

For Healthcare Providers

For Medically Necessary Cases (e.g., Balanophospitis, Balanitis & Emergency Paraphimosis) detailed Medical report/s with confirmed clinical findings, medical management showing no improvements and has been exhausted, must be submitted at the pre-authorization level.

The below ICD-10 codes to be used:

According to the procedure, use the below CPT codes:

References:

• https://bjui-journals.onlinelibrary.wiley.com/doi/pdf/10.1046/j.1464-410x.1999.0830s1045.x
• https://www.nhs.uk/conditions/phimosis/
• https://www.who.int/hiv/pub/malecircumcision/who_mc_local_anaesthesia.pdf?ua
• https://medlineplus.gov/ency/presentations/100081_2.htm
• https://emedicine.medscape.com/article/1015820-clinical
• http://www.childrenshospital.org/conditions-and-treatments/treatments/circumcision
• https://www.columbiaurology.org/staywell/document.php?id=37199
• https://www.health.harvard.edu/a_to_z/balanitis-a-to-z
• NEXtCARE%20Provider%20Procedure%20Manual%20%20UAE%20HUB-2018%20final.pdf

For Members

Immunization

• Immunization is one of the most cost-effective health preventive measure.
• Vaccines are given to build immunity and defense against infections and infectious diseases.
• Vaccines are safe and effective.
• Immunization also slows down or stops disease outbreaks and improves quality of life for societies.
• Some vaccines are effective for lifetime after one (1) dose (e.g. BCG), some require repetitive administrations at prescribed intervals (e.g. Polio) whereas some vaccines require boosters regularly (e.g. Hepatitis-B).
• Administration of vaccine require prior approval from NEXtCARE.
• All children should receive Vaccination.

Dubai (DHA) Policy:

• Vaccine and vaccine administration services for infants & children up to age of 6 Years are generally covered under DHA compliant policies.
• Below schedule is followed based on the recommendation of the Dubai Health Authority (DHA):
• Other vaccines which are not mentioned in the below schedule are not covered.

Reference for DHA:
https://www.dha.gov.ae/Documents/HRD/Immunization%20Guidelines.pdf

Abu Dhabi (DOH) Policy:
Vaccine and vaccine administration services are mostly Excluded under DOH compliant policies.

Northern Emirates (Non-DHA & Non-DOH Policies):
Vaccine and vaccine administration services are covered according to the table of benefits respective to every policy, please always call NEXtCARE to check if vaccines are covered.

For Healthcare Providers

• To correctly report vaccine counselling and administration with these codes, it is important to recognize what the codes are include.
• These codes are limited to immunization administration only.
• Any purchased vaccine products must be separately
• Cost of Vaccine/s is not a part of the Pharmacy limit.

• A face-to-face service where a Physician or other qualified healthcare professional (qualified per Emirate`s Licensing Authority) provides counselling to the patient (patients under 18 years of age and below) and/or to parent, it is required to report 90460-90461.
• In the absence of counselling, the administrations must be reported with codes 90471-90474.
• Code 90460 is reported for each separate administration of single component vaccines and/or first component of a combination vaccine.
• When reporting administration of combination vaccines, code 90460 is reported for the first component and add-on code 90461 is reported for each additional component (modifier-51 is not required).
• All above mentioned codes include “via any route of administration”, that is; regardless of the route of administration (e.g. Subcutaneous, Intramuscular, Injection, Oral, or Intranasal).

For Members

• Preoperative tests are a set of teststhat are carried out before you have a planned (sometimes called ‘elective’) operation.
• These tests might be carried out even if one appears to be healthy, to provide information about conditions that could affect the treatment/surgery performed.
• The tests to be done before your operation/surgery, will be determined by your age, general health condition, any existing illnesses, any medication you are currently taking, and/or the type of operation/surgery.
• The range of preoperative tests recommended by the international guidelines includes (but are not limited to): Complete Blood Count (CBC), Coagulation Profile (PT, PTT), Infections (Hepatitis B&C; Antibody HIV-1 & HIV-2).

For Healthcare Providers

NEXtCARE coverage of pre-operative tests is based on the ASA classification (Table 1), physical examination findings and surgery grade (minor, intermediate, and major/complex) as classified by the American Association of the Family Physician:

(https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system).

Medically justified pre-operative tests, as per the policy terms and conditions of each health insurance plan will be approved only after approval of the in-patient procedure/surgery, if the surgery is not covered, the pre-operative tests also will not be covered. As per the published Guidelines for Preoperative testing by the American College of Cardiology (ACC) and the American Heart Association (AHA), the factors which guide decision making include the surgery specific risks, patient’s cardiovascular risk and functional capacity.(https://www.nice.org.uk/guidance/NG45)

Tests are valid for 6 months (provided there have been no interim change in the patient’s condition, if there have been changes kindly submit all the relevant the reports to justify the repetition of the tests). For patients receiving a preoperative evaluation, code first the reason for the encounter from ICD-10-CM code set Z01.810 to Z01.818:

• Z01.810: “Encounter for pre-procedural cardiovascular examination”
• Z01.811: “Encounter for pre-procedural respiratory examination”
• Z01.812: “Encounter for pre-procedural laboratory examination”
• Z01.818: “Encounter for other pre-procedural examination”

Assign a code for the condition to describe the reason for the surgery as an additional diagnosis to prevent any delays in the approval and to avoid pending of the claim. Example, a patient presents for a preoperative examination for carpal tunnel surgery on the right wrist and has orders from his surgeon for laboratory tests. You would assign diagnosis code Z01.812, as already noted, for the primary diagnosis, and G56.01, “Carpal tunnel syndrome, right upper limb” as the additional diagnosis. Findings related to the preoperative evaluation must be code as well. Basic covered pre-operative tests are:

(https://www.uptodate.com/contents/preoperative-medical-evaluation-of-the-adult-healthy-patient)
Additional pre-operative tests that can be approved according to the member’s comorbidities are listed below:

The below tests are covered for maternity pre-operative procedure if not approved in antenatal care:

(https://www.uptodate.com/contents/overview-of-preoperative-evaluation-and-preparation-forgynecologic-surgery)

Low risk procedures/surgeries:
For low risk procedures/surgeries, Preoperative tests are not covered, until and unless medically indicated. Some examples of low risk procedures/surgeries (but not limited to) are below:

• Breast surgery (e.g. superficial excisional biopsy)
• Eye surgeries (e.g. Cataract)
• Endoscopic procedures
• Ambulatory surgeries
• Dental surgical extractions.

References

• https://www.aafp.org/afp/2002/1115/p1889.html
• https://www.aafp.org/afp/2002/1115/p1889.html
• https://www.medscape.com/viewarticle/556255_6
• https://www.aafp.org/afp/2000/0715/p387.html
• http://ether.stanford.edu/library/cardiac_anesthesia/Cardiology/ACCAHA%20Practice%20Guidelines.pdf
• http://japi.org/april2005/U-306.pdf
• https://www.sciencedirect.com/science/article/pii/S1555415512001092
• http://www.anaesthesia.med.usyd.edu.au/resources/lectures/Preop_JL.html
• http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_Surgery_Adults_Full.pdf
• https://www.sciencedirect.com/science/article/pii/S0001209214010916
• https://www.ama-assn.org/sites/default/files/media-browser/public/physicians/cpt/cpt-molecularpathology-tier-2-codes-january-2017.pdf
• https://www.modahealth.com/pdfs/reimburse/RPM017.pdf

For Members

• Podiatrists are healthcare providers who are specialized in the diagnosis and the treatment of disorders of the foot, ankle and leg (lower limb). They can prevent and correct deformities, relieve pain and treat infections of the lower limbs.

• Chronic conditions like diabetes, peripheral arterial disease and rheumatoid arthritis might require foot care services.

• Many services are rendered by Podiatrists but the most common services covered by insurance plans (but not limited to) are:
  • Diabetic foot.
  • Thick callouses or corns
  • An ingrown toenail
  • A persistent fungal infection in the skin or nails
  • Verruca
  • Bunions

• Referral from physicians will be required, if podiatry services are not mentioned in Table of Benefits/Exclusions of your policy; it shall be analyzed according to the medical necessity.

• If the insurance policy is covering podiatry services under alternative treatment, then referral from Physician is not required.

• Referral from physician is required 1 time per case/condition (multiple sessions/procedures for the same condition do not require multiple referrals).

• Podiatry services related to cosmetic reasons (not medically necessary) will not be approved.

 For Healthcare Providers

• All types of Podiatry Services require Pre-Authorization from NEXtCARE.
• Podiatry services are covered for all plans if medically necessary, not experimental/ investigational, and within the anatomic region of foot-ankle-below knee (proximal extremity of the lower limb).
• The following services may be billed by Podiatrists as ordering and performing clinician:
  • Routine Foot Care (in case the member is suffering from a medical conditions)
  • Surgical Foot Care (post-surgical foot care)
  • Diabetic foot care.
  • Management with prosthetics/ orthotics

• Services performed by Podiatrists at the following anatomical locations will not be covered:
  • Hand
  • Knee and above-knee
  • Unspecified locations

Rejection reason:

• In case of rejection, the rejection reasons for Podiatry Services will be:
  • NCOV-003: Benefit not covered for the member

For Members:

What is Hemodialysis?

Hemodialysis is a process where a machine filters wastes, salts and fluid from the blood when the kidneys are not healthy to function regularly, for example, kidney failure. It helps in controlling the blood pressure and maintaining the proper balance of fluid and minerals in the body. Hence, improving the quality of life.

Measurement of kidney function provides the information to plan the hemodialysis. Your treating physician measures the kidney function by using ‘estimated Glomerular Filtration Rate’ (eGFR). The calculation of eGFR is based on the creatinine blood level, gender, age and any underlying disease, for example, diabetes.

Hemodialysis is a serious responsibility, where you have to:

• Take medications regularly as prescribed by the treating Physician.
• Strictly follow a treatment schedule with regular follow-up with Kidney Doctor.
• Make changes in the diet, especially fluid intake.

What are the Indications?

Hemodialysis is performed in the following conditions:

• Decreased Kidney Function with fluid overload
• Kidney Failure
• eGFR of 5 to 7 ml/min/1.73 m2 but this range may vary according to the age.

What are the common risks/complications of Hemodialysis?

• Low Blood Pressure
• Generalised Weakness
• Muscle & Leg Cramps
• Itching
• Nausea and vomiting
• Headache
• Sleeping problems
• Mood Changes (Anxiety or Depression)
• Anaemia
• Chest and Back pain
• Infection or blockage at the access site

Preparation for hemodialysis:

For a planned Hemodialysis, your physician will prepare a permanent access to your blood stream after informed consent form is signed by you. The access provides a mechanism for a small amount of blood to be safely removed from your circulation and then returned to you in order for the hemodialysis process to work. Adequate time should be given for the healing and stabilizing of the access site.

For emergency Hemodialysis, a plastic tube (catheter) may be inserted into a large vein, either in your neck or near your groin. The catheter is temporary.

For Healthcare Providers:

*14-01 Per Diem-Haemodialysis (HD). Daily all-inclusive rate for out-patient hemodialysis in a dialysis centre provided for a patient. Which shall include:

• Initial and Routine patient assessment prior to, during or after in-centre dialysis treatment.
• Performance of hemodialysis.
• Patient education and support concerning renal disease, dialysis treatment, diet, lifestyle and social aspects.
• Equipment required for the performance of the Hemodialysis.
• All disposable products and supplies required for the performance of the Haemodialysis.
• Medical supervision of the dialysis by qualified physician.
• Pharmaceuticals which are required in the performance of the dialysis treatment.
• All routine investigation tests required for hemodialysis.

Recommendations:

• All Haemodialysis/ Peritoneal Dialysis sessions require pre-approval from NEXtCARE.

• Haemodialysis for the treatment of schizophrenia experimental and investigational because the effectiveness of this treatment has not been demonstrated.

• CPT 90935 cannot be approved in combination with codes 14-01 or 20.10 because the services already included in it.

References:

• https://www.mayoclinic.org/tests-procedures/hemodialysis/about/pac-20384824
• https://www.nice.org.uk/guidance/ng107/chapter/Recommendations
• https://www.merckmanuals.com/professional/genitourinary-disorders/renal-replacement-therapy/hemodialysis
• http://ncu-codefinder-dubai.tatsh.com/reference2/index.html?file=cpttab.ref&topic=CPT.CD.90945&RepId=1&countryName=UnitedArabEmirates&CodeRev=350
• http://ncu-codefinder-dubai.tatsh.com/reference2/index.html?file=cpttab.ref&topic=CPT.CD.90935&RepId=1&countryName=UnitedArabEmirates&CodeRev=350

For Members:

• What is H.pylori Infection?

H.Pylori is a Bacterial infection which grows in the stomach and causes mild to severe acidity. If not treated adequately in a timely manner, it can lead to serious conditions like ulcers and stomach cancer. The infection is more common in adults then in children.

• What are the Signs & Symptoms?
  • Burning pain in your stomach.
  • Pain and cramping near stomach.
  • Increasing in pain and cramping when your stomach is empty.
  • Loss of appetite.
  • Frequent burping.
  • Unplanned weight loss.
  • Mild chest pain without shortness of breath.

• How diagnosis is made?
  • For an infected person, the Bacteria is found in stool, saliva, and dental plaque. Samples can be collected from these locations and the bacteria can be cultured.
  • Your Physician will request a breath test or stool test to confirm the infection.
  • Your treating Physician may recommend to repeat the testing for H. pylori at least four (4) weeks after the treatment. If the test is still positive, it shows that the treatment was unsuccessful, you may undergo another round of treatment and your physician probably prescribe different medications.

• How is the infection transmitted or spreads?

The infection can be transferred from person-to-person, through oral-oral or fecal-oral route. If you or a family member is infected with H.Pylori, then chances of acquiring the infection are higher among the family members.

For Healthcare Providers:

Below is the list of CPT codes related to diagnosis and follow-up on H.Pylori Infection:

* Report 83013 for the breath test analysis and 83014 for the isotope administration and sample collection.

Recommendations:

• Initial diagnosis of H. pylori infection be based on either a positive histopathology plus a positive rapid urease test or a positive culture.
• The 13C-urea breath test (UBT) is a reliable noninvasive test to determine whether H. pylori has been eradicated.
• A validated enzyme-linked immunosorbent assay (ELISA) test for detection of H pylori antigen in stool is a reliable noninvasive test to determine whether H pylori has been eradicated.
• Persons or patients with no gastrointestinal symptoms:
  • a history of peptic ulcer without previous H. pylori eradication (including before taking NSAIDs or low-dose aspirin); or
  • with immunological thrombocytopenic purpura.
• Carbon isotope (13C or 14C) urea breath testing or stool antigen testing are medically necessary for the testing for active Helicobacter pylori infection in selected persons who meet any of the following criteria:
  • Evaluation of new onset dyspepsia in persons younger than 55 years of age without alarm symptoms (anemia, weight loss, vomiting, lymphadenopathy); or
  • Evaluation of persons with persistent symptoms of dyspepsia despite 2 weeks of appropriate antibiotic therapy for Helicobacter pylori (H. pylori); or
  • Before starting proton pump inhibitor therapy for dyspepsia; or
  • Unexplained vitamin B12 deficiency; or
  • immunological thrombocytopenic purpura; or
  • Recurrent dyspeptic symptoms suggesting re-infection with H. pylori; or
  • Re-evaluation to assess success of eradication of H. pylori infection.  (Note: Testing to ensure eradication should occur no sooner than 4 weeks post-treatment).
  • pylori serology is considered experimental because of its inadequate performance. (procedure codes 83009 86677, 87339).

References:

• https://www.merckmanuals.com/professional/gastrointestinal-disorders/gastritis-and-peptic-ulcer-disease/helicobacter-pylori-infection
• https://www.nice.org.uk/guidance/cg184/evidence/appendix-i-information-from-nice-clinical-guideline-17-pdf-6955335253
• https://www.mayoclinic.org/diseases-conditions/h-pylori/symptoms-causes/syc-20356171
• http://ncu-codefinder-dubai.tatsh.com/reference2/index.html?file=cpttab.ref&topic=CPT.CD.83014&RepId=1&countryName=UnitedArabEmirates&CodeRev=350
• https://www.webmd.com/digestive-disorders/urea-breath-test
• https://supercoder.com/
• https://www.mayoclinic.org/diseases-conditions/h-pylori/symptoms-causes/syc-20356171

For Members:

What is Physiotherapy?

• Physiotherapy (physical therapy) is the assessment and treatment of the human body by physical or mechanical means, for the purpose of obtaining, maintaining or restoring a function(s) that has been impaired by injury or age-related deterioration.
• The therapy aims to improve joint and muscle function (e.g., range of motion, strength) and thus improve the patient’s ability to stand, balance, walk, and climb stairs.
• This therapy is provided by means of Physical agents such as LASER, Ultrasound waves, Electric waves, Hot and Cold. Along with physical modalities specialized therapeutic exercises such as mobilization/manipulation of joint and soft tissue, Mayo-fascial release etc. are provided.
• Physiotherapy is provided by specially trained and regulated practitioners called physiotherapists.

Types of Physiotherapies

• Electrotherapy Section: Extracorporeal Shock wave, LASER, Magnetic therapy, TENS, interferential, medium frequency currents, ultrasound, cervical and lumbar traction, wax bath etc. Magnetic Chair therapy and Pelvic Floor Biofeedback for Rehabilitation of patient having urinary incontinence, uterine prolapse & pelvic floor weakness.
• Kinesiotherapy: To improve patient’s strength, range of motion, general exercise and rehabilitation of Neurological and Musculoskeletal cases. Isokinetic assessment and training is done for functional diagnosis and therapy.
• Hydrotherapy: A pool comes with a temperature control for the water and there is a Hubbard tank for pediatric cases.
• Chest Physiotherapy: To improve respiratory functions in patients have breathing difficulty, excessive accumulation of chest secretion.
• Pediatric Rehabilitation: A comprehensive pediatric physical therapy outpatient care focus on many childhood disorders such as Cerebral Palsy, Down’s Syndrome, Muscular Dystrophy, Traumatic Brain Injury, Torticollis, Brachial Plexus injuries, Orthopaedic injuries and Sensory processing disorders. We use advanced quality therapeutic techniques to focus on development training and/or rehabilitation services for the infants to adolescents through comprehensive evaluations based on the child’s needs and the concerns of their parents and Physicians.

Depending on the reason for treatment, the benefits of physical therapy include:

• Pain management with reduced need for opioids.
• Avoiding surgery.
• Improved mobility and movement.
• Recovery from injury or trauma.
• Recovery from stroke or paralysis.
• Fall prevention.
• Improved balance.
• Management of age-related medical problems.

For Healthcare Providers:

• All Physiotherapy sessions require pre-approval from NEXtCARE.
• The maximum approved number of modalities per session is 3 modalities.
• CPT Code 97001: Physical therapy evaluation is to be billed one time only per case, will be approved with the first physiotherapy request only.
• For initial request of physiotherapy:
  • Referral to physiotherapy is required from specialized physician (specialist orthopedics, rheumatologist etc.) in the first physiotherapy request only.
  • Medical report specifying etiology and onset of the condition,
  • If any history of trauma, details of trauma should be mentioned; where, when and how.
• Progress report is required with every subsequent physiotherapy request.
• Kindly submit a detailed medical history report highlighting the following:
• Site, onset and severity of pain/deformity that requires treatment.
• Any previous medical management for the condition with the duration and the outcomes.
• Any supporting radiology reports especially for chronic conditions
• Any history of surgical interventions for the same condition.

Reference:

• https://www.physio-pedia.com/Physiotherapy_/_Physical_Therapy
• https://www.msdmanuals.com/professional/special-subjects/rehabilitation/physical-therapy-pt?query=physiotherapy
• https://www.nhs.uk/conditions/physiotherapy/

For Members

What is Maternity?

• Maternity is the provision of care during pregnancy and immediately before/after childbirth.
• Pregnancy is the term used for the period in which a fetus (baby) develops inside a woman’s uterus.
• In general, there are limits on number of ultrasounds, visits to your Gynecologist and amount utilization limit during pregnancy every policy. Please always check policy always. Exceptions on limits can be made for high risk (score above 10) or low risk (score below 10) pregnancies (Check Table: 1).
• The Risk factors are monitored throughout pregnancy.
• When a maternity claim is submitted, marital status will always be confirmed, including the pregnancy test.
• Generally, declaration of pregnancy should be done at the time of start of the policy. Some policies have a waiting period for maternity benefits, which means that claims will only be accepted after the waiting period.
• Declaration of date of Last Menstrual Period (LMP) is mandatory.
• The maternity benefits might vary among policies from Dubai, Abu Dhabi and Northern Emirates.

Dubai (DHA) Policy:

• Low risk care:
  • Booking Risk Assessment tool (as below) is used to assign a scoring. If identified as low risk, by scoring 9 or less on the, all antenatal care will continue with the Obstetrician or trained GP.
  • Number of antenatal appointments for low risk women:
    • 8 Consultations.
    • 3 ultrasound.
    • 1 anomaly scan.
• High Risk Care:
  • If identified as high risk, by scoring of 10 or more on the Booking Risk Assessment Tool/Continuing Risk Assessment Tool, the member should be referred to hospital for assessment and follow-up by a specialist obstetrician (check Table:2).
  • In case of High Risk pregnancy, your treating physician will decide upon the number of visits and ultrasounds.
• Neonatal circumcision: Check your policy.
• NIPT test is not covered for DHA policies.

Abu Dhabi (DOH) Policy:

1-Down Syndrome screening:

• Combined test between 11 weeks 0 days and 13 weeks and 6 days
  • Nuchal translucency
  • Beta-human chorionic gonadotropin
  • Pregnancy associated plasma protein-A
• Serum screening test (triple or quadruple test) between 15 weeks and 0 days and 20 weeks and 0 days
• Screening for fetal anomalies only recommended for Down syndrome. For Trisomy 18 (Edwards syndrome) and Trisomy 13 (Patau syndrome), kindly check your policy. Generally the screening is included in the NIPT test.

2- Anomaly scan (18-20 weeks)

For a woman whose placenta extends across the internal cervical os, offer another scan at 32 weeks.

3- Coverage of new-born

within 30 days of birth under mother’s card for all services. Coverage can be extended to Out-Patient follow ups & visits within 30 days from birth.

4- Neonatal circumcision:

Check your policy.

Northern Emirates (Non-DHA & Non-DOH Policies):

Please check your policy for details.

For Healthcare Providers:

• All maternity benefits, treatments and screenings require pre-authorization from NEXtCARE.

References:

• https://www.nichd.nih.gov/
• https://www.merriam-webster.com/dictionary/maternity Document Ref. Number: HAAD/ANSC/SD Version 0.9 Approval
• https://www.dha.gov.ae/
• https://www.dha.gov.ae/Asset

For Members:

What is Teleconsultation?

A medical consultation and advice is provided through the information and telecommunication technologies (e.g. Mobile App), for best means for dealing with a medical situation. It takes place between a physician and a patient online, in the case when the patient and the physician are not in the same place.

Tele-diagnosis:

The Physician will determine the condition of the disease or the medical case of the patient via information and telecommunication technologies (e.g. Mobile App).

Tele-prescription of Treatment:

After the tele-diagnosis, the specialized physician would prescribe the treatment, without the clinical examination of the patient, or a situation in which the specialized physician would prescribe treatment remotely based on a diagnosis that has been made using the conventional clinical method.

Tele-medical Monitoring:

The Physician or Nurse will obtain the vital signs of the patient to monitor the condition via information and telecommunication technologies. Tele-medical Intervention.

• NEXtCARE has been providing tele-consultation and treatments through the NEXtCARE Application. Kindly download the App. And enjoy the comfort of the tele-consultation.
• Teleconsultation service will require Pre-approval from NEXtCARE.
• It is limited to one consultation per week for the same Physician and specialty. Follow-up teleconsultation within 7 days in the same provider is free, from date of initial tele- consultation till end of the 7^th day midnight, similar to the normal follow up consultation protocols in the clinics.
• Policy exclusion, limits, sub-limits or general exclusion will be applied as routine according to your policy. Teleconsultation for non-covered conditions will be rejected.

For Healthcare Providers:

Recommendations:

• Teleconsultation service is subject to Pre-approval and limited to one consultation per week for the same specialty.
• Follow-up teleconsultation within 7 days in the same provider is free, from date of initial tele consultation till end of the 7^th day midnight, similar to the normal follow up consultation protocols.
• Consultations within 7 days from the Teleconsultations should not be billed, and teleconsultation will be free.
• Policy exclusion, limits, sub-limits or general exclusion will be applied, Teleconsultation for non-covered conditions will be rejected.

References:

• https://www.doh.gov.ae/en/resources/standards
• http://www.nextcarehealth.com/Media/ViewsDetails?Views_Id=94

For Members

Inflammatory bowel disease (IBD) is an umbrella term used to describe group of disorders that involve chronic inflammation of your digestive tract.

IBS is a disorder of the gastrointestinal (GI) tract. IBD is inflammation or destruction of the bowel wall, which can lead to sores and narrowing of the intestines. It’s possible to have both IBD and IBS.

What is Inflammatory Bowel Syndrome (IBS)?

IBS is not classified as a true disease, it is known as a ‘functional disorder’ (e.g. chronic fatigue syndrome – CFS). This means that the symptoms do not have an identifiable cause. It may be treated with certain medications such as intestinal antispasmodics [e.g., hyoscyamine (Levsin) or dicyclomine (Bentyl)].

What is Inflammatory Bowel Disease (IBD)?

IBD is a relapsing and remitting condition characterized by chronic inflammation at various sites in your gastrointestinal tract, which results in bloody diarrhea, abdominal pain and fever. IBD treatment depends on the type diagnosed. The primary goal is treating and preventing inflammation. Over time, this can damage the intestines. Types of IBD include:

• Ulcerative colitis: This condition causes long-lasting inflammation and sores (ulcers) in the innermost lining of your large intestine (colon) and rectum. Ulcerative colitis is limited to the colon or large intestine.
• Crohn’s disease: This type of IBD is characterized by inflammation of the lining of digestive tract, which often spreads deep into affected tissues. Crohn’s disease can involve any part of the gastrointestinal tract from the mouth to the anus. Most commonly, it affects the last part of the small intestine or the colon or both.

What are Signs & Symptoms?

• Diarrhea that may be bloody.
• Fever and fatigue.
• Abdominal pain/cramps and cramping.
• Blood in your stool.
• Reduced/Loss of appetite.
• Unintended weight loss.
• Severe urgency to have a bowel movement.
• Iron deficiency anemia due to blood loss.

For Healthcare Providers

Recommendations:

• All services require pre-approval from NEXtCARE.

• Endoscopic investigation in patients with chronic colitis is quite accurate for the differential diagnosis between ulcerative colitis and Crohn’s disease, submit the report if already performed.
• Routine Investigations:
  • CBC
  • CRP/ESR
  • Albumin
  • Stool culture
  • Fecal calprotectin
  • Iron studies
  • Celiac Serology

References:

• https://www.webmd.com/ibd-crohns-disease/default.htm
• https://www.msdmanuals.com/professional/gastrointestinal-disorders/inflammatory-bowel-disease-ibd/overview-of-inflammatory-bowel-disease?query=Inflammatory%20Bowel%20Syndrome
• http://ncu-codefinder-dubai.tatsh.com/reference2/index.html?file=cpttab.ref&topic=CPT.CD.45380&RepId=1&countryName=UnitedArabEmirates&CodeRev=360
• https://www.webmd.com/ibd-crohns-disease/inflammatory-bowel-syndrome#1

For Members:

What is Varicose Veins?

• A vein is a blood vessel like an artery which carries low in oxygen blood from all parts of the body to the heart and lungs.
• The legs have rungs (valves) that pushes blood back toward the heart, step by step, without slipping back down. When those valves weaken or collapse, blood and fluid can start to pool in the lower legs, leading to visible veins.
• Veins will bulge with the collection of blood when the blood is not being circulated properly. Enlarged, visible, bulging veins resembling a road map with uncomfortable legs is called Varicose Veins.
• In severe cases, varicose veins can rupture, or can form ulcers on the skin. The most common affected sights are the legs, thighs, calves, ankles, and feet.
• Varicose veins can occur in men or women of any age, but most frequently affecting women of childbearing age and old.
• The possibility of Varicose Veins increases with aging, prolonged standing or immobility (gravity), family history, blood vessel disease, water retention, or pregnancy.
• If you are noticing prominent veins on your legs or thighs with or without pain and discomfort, it is advisable to discuss the problem with your Physician.

What are the recommended treatments?

1- Sclerotherapy is a proven medical procedure used to eliminate varicose veins.

• When sclerotherapy is indicated? Procedures medically necessary for treatment of varicose veins when the following criteria are met:
  • Great saphenous vein or small saphenous vein ligation / division / stripping, radiofrequency endovenous occlusion (VNUS procedure), and endovenous laser ablation of the saphenous vein (ELAS) (also known as endovenous laser treatment (EVLT).
  • Treatment of veins < 3 mm that remain after surgery.
  • Treatment of perforator veins with incompetence or reflux in when surgery is not suitable.
  • Treatment of bleeding varicose veins.
  • Treatment of large varicose veins hidden below venous ulcers.

• What happens during the procedure?
  • During the sclerosing solution (salt or an irritating solution) is injected through a very fine needle directly into the vein, which irritates the lining of the blood vessel, causing it to swell and stick together and the blood to clot. Over some period of time, the vessel turns into scar tissue that fades from the view. Sclerotherapy is performed by a dermatologist or a surgeon, and the procedure itself takes approximately 15 to 45 minutes. Avoid taking drugs like aspirin or ibuprofen for 48-72 hours before sclerotherapy and lotion should not be applied to the legs before the procedure.

• What are the common risks/complications of Sclerotherapy?
  • Itching at the site (lasting for 1 or 2 days after the procedure).
  • You may experience raised, red areas at the injection site, which disappear within a few days.
  • Bruising that can last several days or weeks.
  • Larger veins that have been injected may become lumpy and hard and may require several months to dissolve and fade.
  • Brown lines or spots may appear at the vein that disappear within 3 to 6 months.
  • New, tiny blood vessels may occur at the site of sclerotherapy treatment. These tiny veins can appear days or weeks after the procedure, but should fade within 3 to 12 months without further treatment.
  • Rarely, allergic reactions to the injection fluid may occur at the time of the procedure.
  • After the procedure, you might be instructed to wear support hosiery to “compress” the treated vessels.
  • Inform your Physician immediately if you notice, an inflammation within five inches of the groin, a sudden onset of a swollen leg or formation of small ulcers at the injection site.

• When sclerotherapy is NOT indicated?
  • Spider veins, telangiectasia, reticular veins or small varicose veins (less than 4mm)
  • Treatment of incompetent varicose veins when Radiofrequency ablation or Endogenous laser treatment are suitable.

2- Phlebectomy

Larger varicose veins (>6 mm) are best treated with excision called Phlebectomy. After the excision, once bleeding is controlled, duplex examination will be performed to identify any underlying complications.

3- Laser ablation:

Laser therapy is most effective for small varicose veins and spider veins. Laser therapy applies light energy from a laser onto a varicose vein to shrink it and fade away. For veins to be treated successfully, several sessions may be required, usually at six week intervals.

4- Ligation/stripping:

Vein ligation and stripping is a minor surgery. It is used to remove a damaged vein and prevent complications of vein damage. If several valves in a vein and the vein itself are heavily damaged, the vein (or the diseased part of the vein) is removed (stripped). An incision is made below the vein, a flexible instrument is threaded up the vein to the first incision, and the vein is grasped and removed.

During this surgery, one or more incisions are made over the damaged veins, and the vein is tied off (ligated).

For Healthcare Providers:

• All Sclerotherapy sessions or treatments for Varicose Veins require pre-approval from NEXtCARE.

NICE Guidelines identified the following as priorities for intervention:

• For people with confirmed varicose veins with reflux: Offer endothermal ablation (Radiofrequency ablation or Endogenous laser treatment).
• If endothermal ablation is unsuitable, offer ultrasound-guided foam sclerotherapy.
• If ultrasound-guided foam sclerotherapy is unsuitable, offer surgery.
• If incompetent varicose tributaries are to be treated, consider treating them at the same time.
• Interventional treatment should be avoided during pregnancy.

Varicose Veins Evaluation:

Evaluations determine the type of treatment that needs to be administered. The CPT codes used for those determinations include one radiology code and two codes categorized under Extremity Venous Studies:

Varicose Veins Treatment:

References:

• https://www.webmd.com/skin-problems-and-treatments/spider-and-varicose-veins#1
• https://www.webmd.com/skin-problems-and-treatments/sclerotherapy#1
• https://www.aapc.com/codes/webroot/upload/general_pages_docs/document/sur104.pdf
• https://www.uptodate.com/contents/overview-of-lower-extremity-chronic-venous-disease?search=phlebectomy&source=search_result&selectedTitle=3~9&usage_type=default&display_rank=3
• https://www.uofmhealth.org/health-library/hw113736#:~:text=Vein%20ligation%20and%20stripping%20is,)%20is%20removed%20(stripped).
• NICE Clinical guideline [CG168] Published date: July 2013.
• European guidelines for sclerotherapy in chronic venous disorders April 2013.
• Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) 2015.
• Sclerotherapy for Venous Disease -American venous forum 2016.
• NHS choices – Varicose veins last reviewed 23/03/2017.
• NICE Interventional procedures guidance [IPG557] Published date: May 2016.
• Ultrasound-guided foam sclerotherapy for varicose veins NICE Interventional procedures guidance [IPG440] Published date: February 2013.
• Mayo Foundation for Medical Education and Research (MFMER) 2018.

For Members

• All dental procedures/consultation require prior approval from NEXtCARE
• Dental benefit coverage usually has a limit per year, please always check or ask about your dental limits
• Dental benefits vary according to your insurance coverage plans, please check your poicy details using NEXtCARE App
• Always ask about your dental benefits or check using NEXtCARE App about copayment on dental services before visiting your dentist
• There is no need to do the dental consultation first then the procedure after few days unless medically required
• Approval for dental services is usually granted within 20-30 minutes from the time your healthcare provider submits the request to NEXtCARE
• Cosmetic dental procedures are usually not covered, please check your policy

For Healthcare Providers

• All Dental procedures require Pre-Authorization from NEXtCARE
• Dental consultation should not be billed when a procedure is performed
• Each dental procedure performed requires patients signature on the rendered service document on the date of service rendered
• Specifying the tooth number electronically where applicable
• Only the initial (diagnostic) x-ray can be billed for treatment. Intra-operative x-rays are considered part of the overall service billing and can not be billed for the patients
• Inlays/Onlays:
  • Coverage is allowed only when a tooth cannot be restored with a composite filling
  • Onlays are only covered for posterior teeth
• An x-ray is required for evaluation of the below requests:
  • Crowns
  • Root canal treatment
  • Inlays/Onlays
  • Surgical extractions
  • Impacted teeth extractions
  • Apexification/Apexogenesis
  • Core build up
• Provisional/temporary crowns are not to be billed separately with routine permanent crowns
• Core build up:
  • Allowed when there is severe destruction of the tooth structure (more than half the crown is destructed)
  • Cannot be billed with composite filling/inlays/onlays for the same tooth
• Pulp capping can not be billed when used as liner under a permanent filling
• Pulpectomy and temporary fillings can be billed separately only in cases of emergency procedure for pain relief
• Scaling root planning: A periodontal chart with pocket depth or x-ray showing bone loss is required for approval
• RCT procedure includes pulpectomy and temporary filling

For Members

• What is Allergy Testing?
  • Allergy testing, also known as skin, prick or blood testing, is a method for determining to what substances you are allergic to.
  • Skin allergy testing is relatively a painless form of allergy testing which is reliable.
  • A skin allergy test determines specific allergens based on skin reactions.
  • A small “prick” or puncture is made on the surface of your skin and a minimal amount of certain allergens are put into your skin.
  • Reactions occur within about 15 minutes.
  • You don’t have to wait long to find out what is triggering your allergies.
  • The preferred method is skin test but if it is unsafe or not possible (due to skin condition), the Blood tests are performed. If you are taking certain medications, then blood test will be preferred for testing.
  • Always inform your treating Physician if you are currently using any anti-allergy medications, antidepressants, heart burn or asthma medications because these can interfere with the results.
  • Generally for Abu Dhabi, Dubai and Northern emirates policies, allergy testing is exclusion.
  • Always check benefits and exclusion list in your health insurance policy. All eligible services/benefits require prior-approval from NEXtCARE.

• What are the Indications?
  • Severe dermatitis that excludes skin testing.
  • Patient receiving symptomatic treatment (e.g. anti-allergy drugs).
  • Allergens that cannot be used for skin testing (e.g. toxic, insoluble).
  • Patients with suspected high sensitivity to the allergen where testing could be dangerous.
  • Rhinitis – not controlled by medications and allergen avoidance (e.g., Hay fever).
  • Asthma – ongoing symptoms due to exposure to indoor allergens.
  • Suspected food allergy – based on previous systemic reaction to a certain food.
  • Insect sting (e.g., Bee and Fire ants).
  • Suspected drug allergy – based on previous systemic reaction to a certain drug.
  • Testing drug allergy before starting the treatment (e.g., Penicillin or Omalizumab therapy).
  • Eczema and Dermatitis in children.
  • Recurrent skin infections with pus.

What are the common risks/complications?

• Development of slightly swollen, red, itchy bumps (wheals). These wheals may be more prominent during the test and may disappear in few hours to a couple of days
• Swelling, redness and itching at the site of the test
• itching of the eyes
• itchy and/or runny nose
• Itching of throat
• Light-headedness
• Nausea

For Healthcare Providers

Recommendations:

1. All Allergy testing require pre-approval from NEXtCARE.

2. When clinically significant symptoms exist and conservative therapy has failed.
3. If any of the initial test results is positive, including a total IgE level or a complete blood count (CBC) and white blood cell differential (specifically eosinophils and basophils). Increases in these test results may suggest an allergy, but they may also be elevated for other reasons.
4. Routine repetition of skin tests is not indicated 86001 & 86005 (e.g., annually).
5. Retesting with the same antigen(s) should rarely be necessary within a 3-year period. Exceptions include young children with negative skin tests or older children and adults with negative skin tests in the face of persistent symptoms.

References:

• http://www.pathologylab.org/filesimages/Billing/Allergy%20Testing.pdf
• https://www.aaaai.org/conditions-and-treatments/library/allergy-library/allergy-testing
• https://www.aafp.org/afp/2002/0815/p621.html Østergaard, P. A., Ebbesen, F., Nolte, H., & Skov, P. S. (1990). Basophil histamine release in the diagnosis of house dust mite and dander allergy of asthmatic children: comparison between prick test, RAST, basophil histamine release and bronchial provocation. Allergy, 45(3), 231-235.
• NEXtCARE%20Provider%20Procedure%20Manual%20%20DHA%20%20HAAD-2018%20final.pdf

For Members:

• What is Echocardiography?
  • Echocardiography is a simple test where ultrasound waves are used to produce an image of the heart, the heart valves, and the great vessels. It helps assess heart wall thickness and motion which provides information about any blockage or abnormalities in the heart. It is also used to assess the pumping strength of the heart.
  • Some discomfort may be felt because of ultrasound probe being held very firmly against your chest. This firmness is important to produce the clear images of your heart. Some gel will be applied on your chest at the beginning of the test.
  • The procedure can be performed in the doctor’s office, clinic or a hospital. No special preparations are required. You can eat, drink and take medications as routine.
  • During the test, you may be asked to breathe in a certain way or to hold your breath or to roll onto your left side.
  • If your echocardiogram is normal, no further testing may be needed. Most people can resume their normal daily activities after an echocardiogram.
  • If the results are concerning, you may be referred to a heart specialist (cardiologist) for further investigations.
  • Always check your policy for coverage of investigations.

• What are the Indications?
  • Check for problems with the valves or chambers of your heart.
  • Check if heart problems are the cause of symptoms such as shortness of breath or chest pain.
  • Detect congenital heart defects before birth (fetal echocardiogram).
  • The size and shape of your heart, and the size, thickness and movement of your heart’s walls.
  • How your heart moves.
  • The heart’s pumping strength.
  • If blood is leaking backwards through your heart valves (regurgitation).
  • If the heart valves are too narrow (stenosis).
  • If there is a tumour or infectious growth around your heart valves.

• What are the common risks/complications?
  • No risks are involved in a standard echocardiogram.

For Healthcare Providers:

Recommendations:

• All Echocardiography require approval from NEXtCARE.
• Echocardiography is not covered if done as screening if member does not have Medical Check-up benefit.
• Always submit complete evaluation of the patient which requires complete /detailed medical history of patient, clinical findings and ECG/TMT.
• Echocardiography is not covered if done as screening if member does not have Medical Check-up benefit.
• General indications include, but are not limited to:
  • Evaluation of angina
  • valuation of aortic diseases
  • valuation of aortocoronary bypass grafts
  • Evaluation of atrial fibrillation/flutter
  • Evaluation of cardiomyopathy (including hypertrophic cardiomyopathy (formerly known as idiopathic hypertrophic subaortic stenosis)
  • Evaluation of congestive heart failure
  • Evaluation of dyspnea
  • Evaluation of heart murmur
  • Evaluation of prosthetic valves
  • Evaluation of pulmonary hypertension
  • Evaluation of septal defects
  • Evaluation of site of left-to-right or right-to-left shunts
  • Evaluation of valvular diseases (including mitral regurgitation and severity of valve stenosis).

References:

• https://www.msdmanuals.com/professional/cardiovascular-disorders/cardiovascular-tests-and-procedures/echocardiography?query=Echocardiography
• https://www.mayoclinic.org/tests-procedures/echocardiogram/about/pac-20393856
• http://ncu-codefinder-dubai.tatsh.com/reference2/index.html?file=cpttab.ref&topic=CPT.CD.93308&RepId=1&countryName=UnitedArabEmirates&CodeRev=350
• https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-attack/echocardiogram-echo

For Members:

• What is Fibroscan?

Fibroscan is a test to measures the amount of thickening or scarring of tissues (fibrosis) in the liver. It is also known as transient electrography. This test assist in aaccurately diagnosing liver tissues abnormalities which helps in determining the stage of the liver disease, assessing the patient’s progress, and predicting treatment responses. Most patients will not show any symptoms. However, some might have fatigue, malaise, or abdominal discomfort on the right upper side. The test can be performed with or without ultrasound.

• What are the Indications?
  • In distinguishing hepatic cirrhosis from non-cirrhosis in persons with viral hepatitis e.g., Hepatitis B & C.
  • Drug-induced liver injury.
  • Other chronic liver diseases e.g.:
    • Hereditary hemochromatosis,
    • Primary Biliary cirrhosis.
    • Wilson’s disease.

• When Fibroscan in not Indicated?
  • Fatty (change of) liver, not elsewhere classified.
  • Abnormal results of liver function studies.
  • Autoimmune hepatitis.
  • Non-alcoholic steatohepatitis (NASH).
  • Liver inflammation (e.g. active hepatitis)
  • Bile duct obstruction (e.g. Cholestasis)
  • Mass lesions within the liver (e.g. tumour)
  • Liver congestion (e.g. heart failure)

• What are the common risks/complications?
  • There are no complications for Fibroscan.

For Healthcare Providers:

• ICD and CPT codes must be coded to the highest level of specificity.
• All Fibroscan requests require pre-approval from NEXtCARE.

References:

• https://www.uhn.ca/PatientsFamilies/Health_information/Health_Topics/Documents/FibroScan_Liver_Disease.pdf
• http://www.natap.org/2014/HCV/063014_04.htm
• https://www.nice.org.uk/guidance/ng49
• https://www.uptodate.com/contents/noninvasive-assessment-of-hepatic-fibrosis-ultrasound-based-elastography?search=fibroscan&source=search_result&selectedTitle=2~42&usage_type=default&display_rank=2
• https://www.msdmanuals.com/professional/hepatic-and-biliary-disorders/approach-to-the-patient-with-liver-disease/nonalcoholic-fatty-liver-disease-nafld?query=fibroscan
• https://www.racgp.org.au/afp/2013/july/fibroscan
• http://ncu-codefinder-dubai.tatsh.com/reference2/index.html?file=cpttab.ref&topic=CPT.CD.92100&RepId=1&countryName=UnitedArabEmirates&CodeRev=350

For Members:

• An upper endoscopy is a procedure used to visually examine your upper digestive system with a tiny camera on the end of a long, flexible tube. You have to swallow the tube during the procedure.

• An upper endoscopy requires that you have an empty stomach before the procedure. Do not eat or drink anything for at least six hours before the procedure, or as directed by your doctor or nurse. Ask your doctor for details… Before the upper endoscopy, tell your doctor about any medications (including over-the-counter) or supplements you are taking. If you are Diabetic use insulin, you must adjust the dosage of insulin the day of your upper endoscopy then bring your diabetes medication, if your doctor recommends that you take it after the procedure.

• You will lie on your left side during the procedure.

• Local anaesthetic (pain-relieving medication) may be applied at the back of your throat.

• You will be given a pain reliever and a sedative intravenously (in your vein). You will feel relaxed and drowsy.

• A mouthpiece will be placed in your mouth. It does not interfere with your breathing.

• The doctor will insert the endoscope into your mouth, through your mouth entering into the oesophagus (the food pipe) and into your stomach. The endoscope does not interfere with your breathing.

• Most procedures take 15 to 30 minutes.

• You will stay in a recovery room for about an hour for observation after the procedure.

What are the Indications?

Investigate symptoms: An endoscopy may help your doctor determine what’s causing digestive signs and symptoms, such as nausea, vomiting, abdominal pain, difficulty swallowing and gastrointestinal bleeding.

Diagnose: Your doctor may use an endoscopy to collect tissue samples (biopsy) to test for diseases and conditions, such as anaemia, bleeding, inflammation, diarrhea or cancers of the digestive system.

Treat: Your doctor can pass special tools through the endoscope to treat problems in your digestive system, such as burning a bleeding vessel to stop bleeding, widening a narrow oesophagus, clipping off a polyp or removing a foreign object.

For Healthcare Providers:

Recommendations:

• All Endoscopy sessions will require pre-approval from NEXtCARE.
• When submitting the claim, kindly provide detailed medical report with the below information:
  • Symptoms with onset and duration.
  • Initial conservative treatment with
  • Abdominal US, Common Bile Duct Stones (CBS), stool analysis.
  • Upper GI endoscopy is generally not indicated for evaluating:
  • Symptoms which are considered functional in origin (there are exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy).
  • Metastatic adenocarcinoma of unknown primary site when the results will not alter management.
  • Radiographic findings of:
    • Asymptomatic or uncomplicated sliding hiatal hernia.
    • Uncomplicated duodenal ulcer which has responded to therapy.
    • Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy.
  • Sequential or periodic upper GI endoscopy is generally not indicated for:
• Surveillance for malignancy in patients with gastric atrophy, pernicious anaemia, or prior gastric operations for benign disease.
• Surveillance of healed benign disease such as oesophageal, gastric or duodenal ulcer.
• Surveillance during repeated dilatations of benign strictures unless there is a change in status.
  • Clear indication for endoscopy (refer to indication list below):

Endoscopy under General Anaesthesia (GA):

Diagnostic and uncomplicated therapeutic upper endoscopy and colonoscopy procedures are usually performed with moderate sedation to relieve patient anxiety and discomfort. Indications to perform Endoscopy under General Anaesthesia (GA) are below:

• Patient with previous problems with anesthesia or sedation
• Patient with prescribed or illicit benzodiazepine use
• Alcohol or drug-addicted patients, or patients with an increased tolerance to sedation and analgesic agents (i.e. chronic pain patients treated with opioids),
• Patient undergoing prolonged or complex procedures
• Morbidly obese patients with BMI ≥ 40,
• Patients with documented severe sleep apnea
• Patients younger than 18 years and older than 70 years of age,
• Patients with other documented co-morbid conditions that would prevent safe sedation without anesthesia services (i.e. neurologic conditions such as Parkinson’s, cardiac conditions, uncooperative or combative patients).
• Patient has moderate or severe systemic disease that does not limit the activities (i.e. stable angina or diabetes with systemic sequelae).
• Patient has severe systemic disease that is a constant threat to life (i.e. severe congestive heart failure, end-stage renal disease).
• Recommended CPT codes for the Endoscopy under GA are: 00731-00732 & 00811-00813.

References:

1. https://pubmed.ncbi.nlm.nih.gov/18989141/
2. https://www.webmd.com/heartburn-gerd/guide/upper-endoscopy#1
3. https://www.alfredhealth.org.au/images/resources/referral-guidelines/Endoscopy-Referral-Guidelines.pdf
4. https://www.mayoclinic.org/tests-procedures/endoscopy/about/pac-20395197

For Members:

• What are Hormones?
  • Hormones are chemicals/substances that are produced by your body by different glands. These glands are located with different organs, e.g., brain and kidneys.
  • These chemical messengers travel in your bloodstream to tissues or organs to help them perform their function.
  • The hormones have a tremendous effect on body function and processes. They directly affect growth and development, mood, sexual function, reproduction, and metabolism. Any abnormality (increase or decrease) in the hormones can result into different diseases.
  • Hormones are vital to your health and well-being.

• What are the Indications for Hormonal tests?

Sometimes hormones get out of balance. This can lead to diseases e.g., diabetes, weight gain or loss, infertility, weak bones, and other problems. A specialist in hormones is called an Endocrinologist, who can help you get your body checked and back in balance, if you have a hormone-related condition.

• What are the common risks/complications?

There are no complications for Hormonal test. It’s a simple test which is conducted on a blood sample.

 For Healthcare Providers:

Recommendations:

• All Hormonal Test requests require pre-approval from NEXtCARE.

References:

• https://www.hormone.org/your-health-and-hormones
• https://www.webmd.com/depression/qa/what-are-hormones

For Members:

• What are Tumor Markers?

Tumor Markers is a laboratory test to check substances, often proteins that are produced by the cancer tissue itself or sometimes by the body in response to cancer growth. These substances can be detected in body samples such as blood, urine, and tissue, which helps in detecting and diagnosing some types of cancer, predict and monitor a person’s response to certain treatments, and detect recurrence.

• What are the Limitations of Tumor Markers?
  • Few tumor markers are specific for a particular type of cancer.
  • Not every cancer has a tumor marker that has been identified to be specifically associated with it.
  • Not every person with a particular type of cancer will have an elevated level of the corresponding tumor marker.
  • Many tumor markers may also be elevated in persons with conditions or diseases other than cancer (e.g., Alpha-feto protein which is high for liver cancer but can also be elevated during pregnancy).
  • Tumor markers alone are not diagnostic for cancer; for some types of cancer, they provide additional information that can be considered in combination with your medical history and physical exam performed by your treating physician, in addition to other laboratory and/or imaging tests.

• What are the common risks/complications?

There are no complications for Tumor Marker test.

For Healthcare Providers:

Recommendations:

• All Tumor Marker requests require pre-approval from NEXtCARE.
• Always submit the past medical history of the patient with details of past and current medical and surgical management provided.

References:

• https://www.msdmanuals.com/professional/SearchResults?query=Tumor+Markers#
• https://pubmed.ncbi.nlm.nih.gov/11382139/

For Members:

• What is PURE TONE AUDIOMETRY?

Pure-tone audiometry is a test to measure the hearing ability and sensitivity. The test is conducted in a soundproof booth and you have to wear special headphones. Different pitches of sound will be played and you will be asked to describe what you can hear. In this test, a Pure Tone Thresholds (PTTs) is checked to indicate the softest sound audible to a person, at-least 50% of the time.

Hearing loss can be Temporary or Permanent and be one sided or both sides (Unilateral and Bilateral).

• Types of Hearing Loss:
  • Conductive hearing loss (CHL) is a situation where the sound cannot be transferred from outer ear to the inner ear due to a blockage. The inner ear is working properly but there is blockage in the transmission.
  • Sensorineural hearing loss (SNHL) is a situation where the inner ear is damaged and there is no blockage in the transmission from the outer ear. The inner ear will not function properly due to a hair cell destruction or damage of the ear nerve.

• Reasons for Hearing Loss:
  • At birth (Congenital)
  • Acquired
    • Progressive e.g., Gradual buildup of earwax and/or ear infection
    • Sudden e.g., Damage to the inner ear or eardrum rupture due to high frequency sound.
  • Abnormal bone growths or tumors in the ear
  • Aging
  • Loud noise
  • Heredity/Genetic
  • Work related (Occupational noises or Recreational noises)
  • Side effect of a medications or illness
  • Repetitive Ear infections

Insurance Policy:

For Abu Dhabi (DOH), Dubai (DHA) and Northern Emirates Policies, the test is excluded generally with few exceptions. Please always check your policy details.

For Healthcare Providers:

Recommendations:

• All Pure Tone Audiometry test require pre-approval from NEXtCARE.
• For DOH and DHA policies, pure tone audiometry is a general exclusion.
• Do not report 92557 if you do not complete all required components (pure tone air and bone conduction, speech reception thresholds, and speech recognition testing).  Instead, bill for the individual components of testing using 92552, 92553, 92555, and/or
• If the member is complaining of hearing loss. Otherwise, it will be screening based on Past Medical History or related current complaints.
• Detailed History of present condition and possible contributing factors (Congenital vs Acquired).
• Physical and Neurologic findings. (Otoscope report, Cranial Nerve 8 tests, Weber’s, Rinne’s Test) These are included in the Consultation or Evaluation and Management.

References:

• https://emedicine.medscape.com/article/1822962-overview
• https://www.webmd.com/a-to-z-guides/severe-hearing-loss#3
• https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/hearing-loss/hearing-loss?query=pure%20tone%20audiometry%20quantifies
• https://www.isahd.ae/content/docs/PD%2005-2018.pdf
• https://doh.gov.ae/-/media/0BE585B5E6814D81913697DD6E644C02.ashx

For Members:

• What is Nerve Conduction Study?
  • A nerve is a group of long, thin fibres (thread like structures) that carry information or instructions between the brain and other parts of the body.
  • Nerve signals are electrical impulses that travel quickly throughout your nervous system. Sometimes, problems with the electrical activity in the nerves can cause pain, tingling, or weakness in your muscles.
  • Nerve conduction study (NCS) is the stimulation and recording of electrical activity of the nerves to determine normal activity, to explore abnormal findings, speed and strength of the impulse in the nerve.
  • The test can tell if a nerve is damaged or not. It also helps in the differentiation between nerve and muscle disorders.
  • This study involves activation of the nerves with a very small safe electrical pulse on several points on the skin of the limbs (legs and arms) to measure the responses obtained from nerves.
  • Always check benefits and exclusion list in your health insurance policy. All eligible services/benefits require prior-approval from NEXtCARE.

• What are the Indications? Nerve Conduction studies are performed in following situations:
  • Ongoing Pain or Cramping in the limbs.
  • Continuous Tingling or Numbness of the limbs.
  • Muscle weakness.
  • Detection of the level of a nerve damage or defect.
  • Determining the progress of nerve damage or improvement after treatment.
  • Carpal Tunnel.
  • Tarsal Tunnel Syndrome.
  • Pinched Nerve (Radiculopathy).
  • Single nerve damage (Mononeuropathy).
  • Multiple Nerve damage (Polyneuropathy).
  • Gradual Muscle weakness and wasting (Motor neuropathy).
  • Compression of nerve by blood vessels (Plexopathy).

• What are the common risks/complications?
  • The amount of current given can be uncomfortable but it is safe and tolerable. Your treating physician should explain the procedure in detail.
  • It is highly advisable, not to consume caffeine (tea/coffee) and avoid smoking before the test.
  • In particular, there are no long term side effects of this study.

 For Healthcare Providers:

Recommendations:

• All Nerve Conduction Studies (NCSs) require pre-approval from NEXtCARE.
• It is highly recommended that Physicians should test the fewest number of nerves, needed to assess or diagnose a medical issue when performing an NCS.
• NCS reports should document the nerves evaluated, the distance between the stimulation and recording sites, the conduction velocity, latency values, and amplitude.
• Motor Nerve Conduction Study (CPT codes 95900 and 95903) are performed by applying electrical stimulation at various points along the course of a motor nerve while recording the electrical response from an appropriate muscle. Response parameters include amplitude, latency, configuration, and motor conduction velocity.
• Sensory NCSs (CPT code 95904) is performed by applying electrical stimulation near a nerve and recording the response from a distant site along the nerve. Response parameters include amplitude, latency, configuration, and sensory conduction velocity.
• NCS Codes (BILL ONE CODE PER PATIENT PER DAY only).

References:

• https://www.webmd.com/brain/emg-and-nerve-conduction-study#1
• https://www.sth.nhs.uk/clientfiles/File/EMG%20NERVE%20COND%20Test%20PD3061-PIL969v3.pdf
• https://pubmed.ncbi.nlm.nih.gov/
• https://www.uptodate.com/contents/overview-of-nerve-conduction-studies
• https://www.msdmanuals.com/professional/neurologic-disorders/neurologic-tests-and-procedures/electromyography-emg-and-nerve-conduction-studies?query=nerve%20conduction%20study
• https://jnnp.bmj.com/content/76/suppl_2/ii23
• https://dictionary.cambridge.org/dictionary/english/nerve
• https://www.aapmr.org/docs/default-source/quality-practice/phys-sept19-electrodiagnostic-billing-part-1.pdf?sfvrsn=79835c7c_0

For Members:

• What is MRI?
  • Magnetic Resonance Imaging (MRI) is a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body. MRI scanner is a large tube that contains powerful magnets, you lie on a flatbed that’s moved into the scanner tube.
  • You will be provided earplugs or headphones to wear because inside the MRI scanner tube it is bit noisy. It is extremely important that you stay still during the scanning, otherwise the scan can take longer.
  • You must remove any metal on your body like jewellery or chains or rings.
  • You will be provided with an intercom to communicate with your radiologist during the scanning.
  • It is a painless and safe procedure. The magnetic fields and radio waves used during MRI scan are not harmful. Multiple Researches has confirmed that MRI scans are one of the safest medical procedures available.
  • For Nerves, Brain stem lesions and Spinal cord, MRI is the most suitable investigation.
  • It can be performed with or without contrast (dye). Usually, contrast agents are used to highlight vascular structures and to help characterize inflammation and tumors. Your Physician will inform you if contrast is being used and an allergy test might be performed for contrast before the MRI.
  • MRI scans aren’t usually recommended for pregnant women.
  • Some tattoo ink contains traces of metal, if you have a tattoo on body and feels uncomfortable or burning sensation then immediately informed your radiologist.
  • If a scan is ordered to evaluate headache disorder, MRI with contrast is preferred over CT scan.

• What are the General Indications for MRI Brain?
  • Swelling of the optic nerve.
  • Abnormal Reflexes.
  • Weakness on one side of the face or body.
  • Unsteady gait.
  • Double vision.
  • Vision loss.
  • Abnormalities of pupils.
  • Confusion.

• What are the Specific Indications for MRI Brain (Headaches)?
  • New headache in a cancer patient.
  • Headache in immunocompromised patients.
  • Headache that is becoming worse.
  • Headache in people over age 50.
  • Headache that is not getting better with prescribed medications.
  • Persistent headache after head injury.
  • Persistent fever.

• What are the Specific Indications for MRI Brain for children?
  • Detect a variety of brain conditions and abnormalities like cysts, tumors, bleeding, swelling, or problems with the blood vessels
  • In cases of head injuries.
  • Diagnose infectious or autoimmune diseases like encephalopathy or encephalitis
  • Persistent headaches, dizziness, weakness, blurry vision or seizures
  • Diagnose problems with the pituitary gland and brainstem
  • Assess the cause of developmental delay (please ask if your insurance policy is covering developmental delay).

• When MRI Brain is NOT indicated in People who:
  • Meet the criteria of migraine.
  • No abnormal findings on examination.Have not had a significant change in headache pattern.
  • People with mild intermittent headaches which are managed and have no red flags.
  • Patients who have a heart pacemaker may not have an MRI scan.
  • Patients who have a metallic foreign body (metal sliver) in their eye, or who have an aneurysm clip in their brain, cannot have an MRI scan since the magnetic field may dislodge the metal.
  • Patients with severe claustrophobia may not be able to tolerate an MRI scan, although more open scanners are now available, and medical sedation is available to make the test easier to tolerate.
  • MRI scans aren’t usually recommended for pregnant women.

 For Healthcare Providers:

Recommendations:

• All MRI require pre-approval from NEXtCARE.
• Always submit detailed history of the sign & symptoms with onset and duration of the disease.

References:

• https://www.nhs.uk/conditions/mri-scan/
• https://www.msdmanuals.com/professional/neurologic-disorders/neurologic-tests-and-procedures/magnetic-resonance-imaging-mri-in-neurologic-disorders?query=MRI%20Brain

For Members:

• What is MRI?
  • Magnetic Resonance Imaging (MRI) is a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body. MRI scanner is a large tube that contains powerful magnets, you lie on a flatbed that’s moved into the scanner tube.
  • You will be provided earplugs or headphones to wear because inside the MRI scanner tube it is bit noisy. It is extremely important that you stay still during the scanning, otherwise the scan can take longer.
  • You will be provided with an intercom to communicate with your radiologist during the scanning.
  • The magnetic fields and radio waves used during MRI scan are not harmful. Multiple Researches has confirmed that MRI scans are one of the safest medical procedures available. It is a painless and safe procedure.
  • An X-ray takes pictures of your bones, whereas knee MRI lets your Physician see your bones, cartilage, tendons, ligaments, muscles, and even some blood vessels. The test can show a range of problems, including: Damaged cartilage, Torn tendons or ligaments, Bone fractures, Osteoarthritis, Infections, and Tumors etc.
  • This investigations also helps in deciding if the surgery is required for the knee or if you are healing efficiently with a treatment prescribed by your physician.
  • It can be performed with or without contrast (dye). Usually, contrast agents are used to highlight vascular structures and to help characterize inflammation and tumors. Your Physician will inform you if contrast is being used and an allergy test might be performed for contrast before the MRI.

• What are the General Indications for MRI Knee?
  • Painful Swelling or clicking or Locking in the knee for more than 4-6 weeks.
  • If there is clinical suspicion of internal derangement.
  • When plain X-ray has excluded fracture, osteoarthritis and osteochondral defects.
  • Prolonged, refractory, or unexplained knee pain.
  • Patients with recurrent, residual, or new symptoms following knee surgery.
  • Detection, staging, and post-treatment evaluation of tumor of the knee.
  • Persistent knee pain/swelling and/or instability (giving way) not associated with an injury and not responding to at least 3 weeks of medical treatment.
  • Persistent knee pain/swelling and/or instability (giving way) secondary to an injury and not responding to conservative therapy when multi-view x-rays have ruled out a fracture or loose body in the knee and the clinical picture remains uncertain.
  • Persistent true locking of the knee indicative of a torn meniscus or loose body.
  • Suspected bone infection (i.e., osteomyelitis).
  • To diagnose or evaluate rheumatoid arthritis or degenerative joint disease.

• What are the Specific Indications for MRI Knee:
  • ACUTE (FOUR TO SIX WEEKS):
  • Traumatic injury with inability to fully extend the knee, younger patient (rule out bucket-handle meniscus tear).
  • Anterior cruciate ligament tear suspected, young athlete (may have other injuries such as meniscus tear).
  • CHRONIC (TWO TO THREE MONTHS):
  • Continued knee pain with suspected surgical pathology, older patient.
  • Persistent unexplained knee pain (rule out surgical pathology).

• When MRI Knee is NOT indicated in:
  • In the assessment of the acutely painful knee or where careful examination does not reveal signs of cruciate or collateral ligament or meniscal injury.
  • MRI does not usually provide additional information where degenerative joint disease is evident on plain X-rays.
  • Patients who have a heart pacemaker may not have an MRI scan.
  • Patients who have had metallic devices placed in their legs or back (such as pedicle screws or anterior interbody cages) can have an MRI scan, but the resolution of the scan is often severely hampered by the metal device and the spine is not well imaged.
  • Patients with severe claustrophobia may not be able to tolerate an MRI scan, although more open scanners are now available, and medical sedation is available to make the test easier to tolerate.
  • MRI scans aren’t usually recommended for pregnant women.

 For Healthcare Providers:

• All MRI require pre-approval from NEXtCARE.
• In rare situations (Meniscal injury, ACL injury, articular cartilage injury, collateral ligaments injury), MRI can be approved for both knees, when it is suspected during clinical examination and after excluding osteoarthritis by x-ray,
• Always submit detailed history of the sign & symptoms with onset and duration of the disease.
• Laboratory findings and Plain x-ray report must be submitted.

References:

• https://www.nhs.uk/conditions/mri-scan/
• https://www.msdmanuals.com/professional/neurologic-disorders/neurologic-tests-and-procedures/magnetic-resonance-imaging-mri-in-neurologic-disorders?query=MRI%20Brain
• http://ncu-codefinder-dubai.tatsh.com/reference2/index.html?file=cpttab.ref&topic=CPT.CD.70553&RepId=1&countryName=UnitedArabEmirates&CodeRev=350
• https://www.aafp.org/afp/2011/0415/p883.html
• https://www.racgp.org.au/afp/2012/november/mri-of-the-knee/#:~:text=What%20are%20the%20indications%3F,clinical%20suspicion%20of%20internal%20derangement.
• https://www.msdmanuals.com/professional/special-subjects/principles-of-radiologic-imaging/magnetic-resonance-imaging?query=MRI%20knee
• https://www.webmd.com/pain-management/knee-pain/what-expect-knee-mri#1
• http://www.oxfordshireccg.nhs.uk/professional-resources/documents/clinical-guidelines/MSK-and-physio/knee/knee-MRI-referral-guidelines.pdf

For Members:

• What is Cardiovascular Stress Test?

It is an exercise stress test where heart’s electrical activity is checked while you are exercising to estimate the risk of heart diseases. Any abnormalities identified in the electrical activity indicates the presence of heart vessels disease. It is also known as ‘treadmill test’. During the test, the treadmill speed and slope is gradually increased at roughly 3-minute intervals.

It is highly recommended that you should not take heart/chest discomfort medications on the day of your test, unless your doctor advices. The test is performed on empty stomach that is why do not drink or eat anything at-least 4 hours before the test. Consuming caffeine 12 hrs before the test is strictly prohibited.

• What are the Indications?
  • Symptoms like chest pain on excursion.
  • Recent Heart attack (Acute Coronary Syndrome) treated without angiography.
  • Known Heart vessel diseases with worsening symptoms.
  • Patients with Coronary artery bypass grafting (CABG) done for 5 years or longer.
  • Patients with Percutaneous Coronary Intervention (PCI)done for 2 years or less.
  • Valvular heart disease (to assess exercise capacity and need for surgical intervention)
  • Certain cardiac arrhythmias to assess the effect of heart stimulating medication (chronotropic competence).
  • Newly diagnosed heart failure or abnormalities.

• What are the Contraindications?
  • Acute aortic dissection.
  • Acquired complete heart block.
  • Decompensated heart failure.
  • Inability to exercise.
  • Heart attack in previous two days.
  • High heart rate with palpitations (100 or above).
  • Slow heart rate (60 or below).
  • Heart Muscles Weakness.
  • Ongoing unstable Angina.
  • Symptomatic severe aortic stenosis.
  • Uncontrolled cardiac arrhythmia with hemodynamic compromise.
  • Known coronary artery disease.
  • Recent stroke.
  • Resting systolic blood pressure >200 mm Hg or diastolic blood pressure >110 mm Hg.

 For Healthcare Providers:

Recommendations:

• All Cardiovascular Stress Test require prior approval from NEXtCARE.
• The drug (if used) is not separately billable by the Physician. The IV administration of the drug (CPT codes 90765, 90768, 90772, 90774) is considered included in the stress test.
• Additional modifier (CPT codes 93015, 93016, 93018) is not needed with the above mentioned codes.

References:

• https://www.webmd.com/heart-disease/guide/stress-test#1
• https://www.aafp.org/afp/
• https://www.aafp.org/afp/2
• https://www.msdmanuals.com/professional/cardiovascular-disorders/cardiovascular-tests-and-procedures/stress-testing?query=cardiovascular%20stress%20test
• https://www.ncbi.nlm.nih.gov/books/NBK499903/

For Members:

• What is Breast Screening?
  • Breast Screening is of utmost importance in early diagnosis of the cancers and timely treatments.
  • The earlier the cancer is diagnosed, the better are the outcomes in terms of survival and quality of life.

• The most common types of screenings are:
  • Self-Exam
  • Mammograms
  • Ultrasound

• Screening Recommendations:
  • 40 to 44: Have the choice to start yearly mammogram.
  • 45 to 54: Get yearly mammograms.
  • 55 and older: Either a mammogram every other year or continue getting yearly mammograms.

• Risk Factors of Breast cancers:
  • Age: 50 or above.
  • Family history: Having a 1st-degree relative (mother, sister, and daughter).
  • Personal history: Having a situ or invasive breast previously.
  • Gynecologic history: Early menstruations, late menopause, or late first pregnancy.
  • Breast changes: History of a lesion/s that required a biopsy increases risk slightly.
  • Oral contraceptives Use: Oral contraceptive use increases risk very slightly.
  • Hormone therapy: Postmenopausal hormone (estrogen plus a progestin).
  • Radiation therapy: Exposure to radiation therapy before age 30 increases risk.
  • Diet: Diet may contribute to development or growth of breast cancers e.g. high in fats.
  • Obesity: Obese postmenopausal women are at increased risk).
  • Lifestyle factors: Smoking and alcohol.

1- What is Breast Self-Exam?

Self-Exam can be performed in front of large mirror in a well-lit room in your home. Ask your physician to explain how to perform the exam. It is very simple, cost effective, and easy to identify any lump or cyst and identify any abnormality in the breast. It is recommended to perform breast exam every month after menstrual cycle.

2- What is Diagnostic mammography?

Mammography uses special X-ray images to spot abnormal growths or changes in breast tissue.

Using a digital X-ray machine made especially for breast tissue, a technician takes pictures from at least two angles to make a set of images for each of your breasts. Diagnostic mammography is performed to evaluate patients who have signs and/or symptoms of breast abnormalities or disease.

Indications:

• Abnormality found on screening mammogram.
• Short interval follow up of probably benign but abnormal mammogram.
• Patient/physician identified breast lump.
• Focal breast pain/tenderness.
• Suspected Abscess.
• Spontaneous nipple discharge.
• New nipple changes (e.g. inversion).

3- What is the Breast ultrasound?

A breast ultrasound is a painless procedure that uses sound waves to make images of the inside of your breast. The sound waves bounce off surfaces in your body, and the “echoes” are recorded to make video or image. A common indication for breast ultrasound is evaluation of an abnormal finding observed on mammography, to decide if further investigation or intervention is required or not based on the breast density. The breast density will be reported by categories of BI-RADS (Table-1).

Indications:

• Palpable lump; axillary adenopathy.
• First diagnostic approach for clinical abnormalities under 40 and in pregnant or lactating women (due to density of the breast tissue).
• Suspicious abnormalities on mammography or breast MRI.
• Suspicious nipple discharge.
• Recent nipple inversion.
• Skin retraction.
• Breast inflammation; abnormalities in the area of the surgical scar after breast conserving surgery or mastectomy (surgical removal of Breast/s).
• Abnormalities in the presence of breast implants.
• Screening high-risk women (family history), especially when MRI is not performed.
• Location & Breast Region based staging of a known breast cancer, when MRI is not performed.
• Guidance for percutaneous interventions (needle biopsy, pre-surgical localization, fluid collection drainage).
• Monitoring patients with breast cancer receiving initial therapy, when MRI is not performed.
• Supplemental screening after mammography for women aged 40–74 with dense breasts.

Table-1

For Healthcare Providers:

Recommendations:

• All Breast Screening (Mammography & Ultrasounds) will require pre-approval from NEXtCARE.
• Diagnostic mammography will not be covered for screening purpose unless it is covered under well-being or screening benefits.
• Diagnostic mammography will be covered for diagnosed conditions and/o for members with signs and symptoms only.
• Claims will not be approved when both screening and diagnostic mammography are billed together for the same patient on the same day.
• Screening mammography will be approved only if ‘Preventive screening’ Or ‘Routine Health Check Up’ is covered, otherwise diagnostic screening codes should be used if the member is symptomatic.
• Ultrasound can determine whether the lesion is a simple cyst or skin lesion requiring any intervention or not and if a suspected malignancy requires a biopsy or not.
• Only Breast Ultrasound will be approved without mammography when:
• If the member is under age 40.
• If breast problems/symptoms are observed while pregnant.
• If there is a cyst that needs to be drained.

References:

• https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/mammograms/understanding-your-mammogram-report.html
• https://www.who.int/cancer/detection/breastcancer/en/
• https://www.msdmanuals.com/professional/gynecology-and-obstetrics/breast-disorders/breast-cancer?query=Breast%20Screening
• https://www.cancer.org/healthy/find-cancer-early/cancer-screening-guidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer.html#:~:text=Women%20ages%2040%20to%2044,or%20can%20continue%20yearly%20screening.
• https://www.hcpro.com/HOM-55502-2977/Clearing-up-the-confusion-CPT-codes-76376-and-76377.html

For Members:

Ultrasound:

• Ultrasound is also called sonography.
• Ultrasound is an imaging technique, bouncing sound waves far above the level of human perception through interior body structures. The sound waves pass through different densities of tissue and reflect back to a receiving unit at varying speeds. The unit converts the waves to electrical pulses that are immediately displayed in picture form on a computer screen, to determine the size, shape, and consistency of soft tissues and organs.
• Real time scanning displays both two-dimensional structure images and movement with time.
• Images produced can be flat 2 dimensional, 3D and 4D where 3D images are seen in motion.
• Ultrasound technicians, or sonographers, have special training in performing the test. Then a radiologist or your Physician will interpret the ultrasound images to make diagnosis.
• During ultrasound, the technician will apply a water-based gel to the area, this helps the transducer (probe) can easily glide across your skin without any air in between.
• Typically an ultrasound takes between 30 minutes and an hour.
• Ultrasound imaging can help in some medical procedures such as needle biopsies.
• It can useful for detecting and treating soft-tissue injuries.
• It is a non-invasive, painless and harmless test with no radiations involved.
• It is readily available and affordable test.
• This technology is very helpful in diagnosing and treating certain conditions affecting heart and blood vessels, liver, gallbladder, spleen, pancreas, kidneys, bladder, uterus, ovaries, eyes, thyroid, and testicles.

Types of Ultrasound:

Depending on the organ being examined and the underlying disease, different transducers (probes) are used during Ultrasound. Based on the type of ultrasound test you are having, your Physician may provide special instructions, such as not eating or drinking anything for a number of hours before the test, or drinking or eating in certain quantity, always follow the instructions.

1- Abdominal Ultrasound

• Abdominal ultrasonography is most commonly used to obtain images of abdominal organs like, liver, kidneys, gall bladder and some parts of small intestine.
• It is usually performed after 8-10 hours of fasting. It can be difficult for patients with gas in intestine or obesity (belly fat).
• Abdominal ultrasound may be performed to assist in the placement of needles used for biopsy of abdominal tissue or to drain fluid from a cyst or abscess.
• It may also be used to assess the blood flow of various structures within the abdomen.
• Indications:
  • Abdominal, flank, and/or back pain.
  • Evaluation of urinary tract infection and hydronephrosis (kidney disease).
  • Evaluation of uncontrolled hypertension and suspected renal artery stenosis (collapse).
  • Search for the presence of free or loculated peritoneal and/or retroperitoneal fluid.
  • Evaluation of suspected congenital abnormalities.
  • Evaluation of suspected hypertrophic pyloric stenosis, intussusception, necrotizing enterocolitis, or any other bowel abnormalities.
  • Before and after transplantation evaluation.
  • Signs or symptoms that may be referred from the abdominal and/or retroperitoneal regions, such as
    • Jaundice or Hematuria (blood in Urine)
    • Palpable abnormalities such as an abdominal mass or organomegaly
  • Abnormal laboratory values or abnormal findings on other imaging examinations suggestive of:
    • Abdominal and/or retroperitoneal pathology.
    • Follow-up of known or suspected abnormalities in the abdomen and/or retroperitoneum.
    • Search for metastatic disease or occult primary neoplasm.
    • Evaluation of cirrhosis, portal hypertension, and Trans-jugular Intrahepatic Portosystemic Shunt (TIPS).
    • Stents; screening for hepatoma; evaluation of the liver in conjunction with liver elastography.
    • Abdominal trauma.
  • It can also be helpful in checking other abdominal conditions, like:
    •  Cysts
    •  Tumors
    • Collection of pus (abscesses)
    •  Obstructions
    • Fluid collection
    • Blockages (clots) in blood vessels

2- Pelvic Ultrasound:

• It is performed on the lower abdomen, that is, below umbilicus (belly button).
• It can be performed by placing a probe on lower abdomen directly or by inserting a small probe in the vagina.
• It may be necessary to use a transvaginal ultrasound to examine the following internal organs: Vagina, cervix, uterus, fallopian tubes, ovaries, urinary bladder and are also useful to check for ovarian cysts or tumors, fibroids and polyps.
• Transvaginal ultrasound is preferred over CT because of improved visualization of pelvic organs, the absence of radiation exposure with ultrasonography, decreased time of hospital stay, and reduced cost to the patient.
• Transvaginal ultrasound is not performed in virgin patients or if the patient is unable to tolerate internal examinations.
• Indications:
  • Evaluation of pelvic pain
  • Evaluation of pelvic masses
  • Evaluation of endocrine abnormalities, including polycystic ovaries
  • Evaluation of dysmenorrhea (painful menses)
  • Evaluation of amenorrhea (absence of menses)
  • Evaluation of abnormal bleeding
  • Evaluation of delayed menses
  • Follow-up of a previously detected abnormality
  • bleeding);
  • Excessive irregular bleeding (Menometrorrhagia)
  • Evaluation, monitoring, and/or treatment of infertility patients
  • Delayed menses
  • Postmenopausal bleeding
  • Signs or symptoms of pelvic infection
  • Evaluation of congenital anomalies (birth defects) during pregnancy
  • Abortion
  • Localization of a intrauterine contraceptive device (IUCD)
  • Screening for malignancy (cancer) in patients at increased risk
  • Urinary incontinence
  • Pelvic organ prolapse
  • Guidance for interventional or surgical procedures

3- Scrotal ultrasound:

• It can provide detailed pictures of scrotum, testicles, and the blood vessels. Doctors also call this test a “scrotal ultrasound.
• Your Physician might order this test if you have pain or swelling, or if you have a mass in the scrotum.
• It can also assist in identifying whether there is a cyst (fluid-filled sac), or torsion.
• An ultrasound can also be used to diagnose testicular cancer or problems with blood flow in the scrotum.
• Indications:
  • For Newborns/Infants/children:
    • To determine the presence of testes in the case of cryptorchidism.
    • Testicular pain.
    • Suspected orchitis and epididymitis.
    • Testicular and epididymal asymmetry.
    • Abnormal laboratory and tumor marker findings, e.g. alpha-fetoprotein and human chorionic gonadotropin (β-HCG).
  • For Adults:
    • Abnormal testicular consistency.
    • Suspected testicular tumors.
    • Scrotal or inguinal hernia.
    • Spermatic cord hydrocele.
    • Extra peritoneal and inguinal lymphadenopathy.
    • Hematospermia (blood in semen)
    • Reproductive failure.

For Healthcare Providers:

• All Ultrasound request/s require pre-authorization from NEXtCARE.

References:

• https://www.webmd.com/a-to-z-guides/what-is-an-ultrasound#1
• http://ncu-codefinder-dubai.tatsh.com/reference2/index.html?file=cptlinks.ref&topic=76811&RepId=1&countryName=UnitedArabEmirates&CodeRev=360
• https://www.uptodate.com/contents/transabdominal-ultrasonography-of-the-small-and-large-intestine?search=abdominal%20ultrasound&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
• https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/abdominal-ultrasound
• https://onlinelibrary.wiley.com/doi/10.7863/jum.2010.29.1.166
• Alcazar JL, Gaston B, Navarro B, et al. Transvaginal ultrasound versus magnetic resonance imaging for preoperative assessment of myometrial infiltration in patients with endometrial cancer: A systematic review and meta-analysis. J Gynecol Oncol. 2017;28(6):e86
• Guerriero S, Ajossa S, Orozco R, et al. Accuracy of transvaginal ultrasound for diagnosis of deep endometriosis in the rectosigmoid: Systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2016;47(3):281-289.
• radiologyinfo.org/en/info.cfm?pg=us-scrotal

For Members:

• What is MRI?
  • Magnetic resonance imaging (MRI) is a radiation-free, non-invasive, technique that uses strong magnetic fields to produce high quality, detailed and sectional images of the inside of the body in multiple planes.
  • The magnetic fields and radio waves used during MRI scan are not harmful. Multiple Researches has confirmed that MRI scans are one of the safest medical procedures available.
  • MRI can detect fractures that are not visible on X-rays and major ligament/tendon damage to important structures inside a joint.
  • It is a painless and safe procedure; anaesthesia or sedation is not needed usually.
  • It can be performed with or without contrast (dye). Usually, contrast agents are used to highlight vascular structures and to help characterize inflammation and tumors. Your Physician will inform you if contrast is being used and an allergy test might be performed for contrast before the MRI.
  • Some tattoo ink contains traces of metal, if you have a tattoo on body and feels uncomfortable or burning sensation then immediately informed your radiologist.

• What are the General Indications for MRI Shoulder?
  • Suspected rotator cuff tear or sprain.
  • Trauma and diffuse axonal injuries.
  • Shoulder instability.
  • Osteonecrosis.
  • Tumors and masses.
  • Infection.
  • Degenerative joint disorders such as arthritis and labral tears.
  • For needle phobic patients who cannot tolerate an arthrogram.

• When MRI is NOT indicated for Shoulder:
  • Frozen shoulder is a clinically diagnosed (age, gender & history) and does not need any specific diagnostic scans.
  • For the frozen shoulder the MRI is not generally helpful. The arthrogram is more helpful because it shows small joint space (i.e. less than 14 ccs).

• What is Arthrogram?
  • It is a type of imaging, which is also called Arthrography.
  • Arthrography can be used to view torn ligaments and fragmented cartilage in the joint.
  • First, using a thin long needle, a special dye, called contrast dye, is injected into your joint directly.
  • Then, the joint is scanned using X-ray, CT scan or MRI.
  • The dye helps in highlighting the problem in your joint.
  • Later, the fluid may be aspirated and sent to a lab for analysis.
  • During the same procedure, medication may be injected into the joint as treatment.
  • The arthrogram is diagnostic of acute full thickness rotator cuff tears more so than MRI only.
  • Other than acute, full thickness rotator cuff tears, all other types of rotator cuff tears, i.e., smaller or incomplete tears are treated based on non-responsiveness to conservative care.
  • Mostly arthrography is used to examine the knee and shoulder joints, it can also be used to examine other small joints, such as the wrist, ankle, hip, elbow or prosthetic joints.

• What are the General Indications for Arthrogram?
  • Rotator cuff tear—mainly for complete tears.
  • Adhesive capsulitis.
  • Rotator interval tear.
  • Glenoid labrum tear.
  • Septic arthritis.
  • Prosthetic loosening or infection.
  • Part of MR arthrogram.
  • Biceps tendon injury.

For Healthcare Providers:

 All MRI require pre-approval from NEXtCARE.

• Always submit detailed history of the sign & symptoms with onset and duration of the disease.
• In case of Shoulder pain without trauma, kindly provide:
• Onset and duration of the current condition.
• Conservative management provided, with duration and response.
• Complete physical examination and neurological findings.

References:

• https://www.webmd.com/arthritis/what-is-an-arthrogram
• https://www.nhs.uk/conditions/mri-scan/
• https://www.msdmanuals.com/professional/neurologic-disorders/neurologic-tests-and-procedures/magnetic-resonance-imaging-mri-in-neurologic-disorders?query=MRI%20Brain
• https://www.msdmanuals.com/home/bone,-joint,-and-muscle-disorders/diagnosis-of-musculoskeletal-disorders/tests-for-musculoskeletal-disorders?query=arthrography#v37122810
• https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/arthrography

For Members:

• What is MRI?
  • Magnetic resonance imaging (MRI) is a radiation-free, non-invasive, technique that uses strong magnetic fields to produce high quality, detailed and sectional images of the inside of the body in multiple planes.
  • The magnetic fields and radio waves used during MRI scan are not harmful. Multiple Researches has confirmed that MRI scans are one of the safest medical procedures available.
  • An MRI scan is performed as an outpatient procedure; you are not required to stay in the hospital overnight.
  • You will be provided earplugs or headphones to wear because inside the MRI scanner tube, it is bit noisy.
  • It is a painless and safe procedure; anaesthesia or sedation is not needed usually.
  • For post-operative scarring, or an infection or spinal tumor is suspected, contrast material is very likely to be used during the scan.
  • For a patient who has already under gone the spinal surgery, contrast agent is helpful in differentiating a recurrent or remaining disc herniation from scar tissue.
  • MRI scans aren’t usually recommended for pregnant women.
  • At the initial onset of spine-related pain, it is not usually necessary to obtain an MRI scan because most cases of back pain will resolve within 2 to 12 weeks with proper conservative (non-surgical) treatment.
  • If conservative treatment is not effective and more aggressive back pain treatments (e.g. injections or surgery) are contemplated to relieve the symptoms, then MRI scans are needed.

• What are the General Indications for MRI Lumbar Spine?
  • Suspicious of Cancer or Metastases.
  • Spinal Infection (Abscess, Arachnoiditis, Discitis, Osteomyelitis).
  • Fracture or trauma.
  • Cauda quine or Ankylosing spondylitis or radicular compression.
  • Post-operative or post-procedure evaluation.

• What are the Specific Indications for MRI Lumbar Spine?
  • The below symptoms require MRI regardless of the duration of the symptoms:
    • Abnormal reflexes in the lower body (may indicate disruption of the nerves that enable sensation and movement).
    • Foot Drop (inability to lift your foot).
    • Dysfunction or loss of bowel and/or bladder control.

For Healthcare Providers:

• All MRI require pre-approval from NEXtCARE.
• Always submit detailed history of the sign & symptoms with onset and duration of the disease.
• For the majority of patients with acute low back pain, symptoms and/or physical exam findings will improve or resolve during a trial of conservative treatment and diagnostic imaging is not necessary.
• In case of trauma, kindly provide:
  • Details of trauma (when, where and how).
  • Neurological findings.
  • If X-Ray is already done, please provide the report.
• In Case without trauma, kindly provide:

• Onset and duration of the condition.
• Conservative management done and for how long and how was the response.
• Complete physical examination and neurological findings.
• Signs and symptoms of severe radiculopathy or spinal stenosis.

• The CPT code assignment for an MRI procedure is based on the anatomic area being examined, kindly submit accurate CPT.
• Requests for multiple MRI imaging of the same anatomic area to address patient positional changes, additional sequences or equipment are not good medical practices. These variations or extra sequences are included within the original imaging request.
• Avoid submitting additional/multiple unnecessary CPTs.

References:

• https://pubmed.ncbi.nlm.nih.gov/
• https://www.ajronline.org/doi/pdf/10.2214/AJR.10.4367
• https://www.cmi4mri.com/providers/cpt-codes
• https://aimspecialtyhealth.com/guidelines/PDFs/2017/Sept05/AIM_Guidelines_Spine.pdf
• https://www.nhs.uk/conditions/mri-scan/
• https://www.msdmanuals.com/professional/special-subjects/principles-of-radiologic-imaging/magnetic-resonance-imaging
• https://www.spine-health.com/treatment/diagnostic-tests/mri-scan-spine

For Members:

• What is MRI?
  • Magnetic resonance imaging (MRI) is a radiation-free, non-invasive, technique that uses strong magnetic fields to produce high quality, detailed and sectional images of the inside of the body in multiple planes.
  • MRI scanner is a large tube, open at both ends that contains powerful magnets, you lie on a flatbed that’s moved into the scanner tube.
  • If you have fear of enclosed spaces (claustrophobia) or anxiety, inform your Physician.
  • An MRI scan is performed as an outpatient procedure; you are not required to stay in hospital overnight.
  • It is a painless and safe procedure; anaesthesia or sedation is not needed.
  • The magnetic fields and radio waves used during MRI scan are not harmful. Multiple Researches has confirmed that MRI scans are one of the safest medical procedures available.
  • MRI scans aren’t usually recommended for pregnant women.
  • An MRI can be used to detect tumours and cysts of the pelvis, urinary tract, diseases of the small intestine as well as causes of pelvic pain in women such as fibroids, endometriosis, adenomyosis and other abnormalities of the reproductive organs

• What are the General Indications for MRI Pelvis?
  • Birth defects.
  • Injury or trauma in the pelvic area.
  • Abnormal X-ray or Ultrasound results (to further investigate).
  • Ongoing pain in the lower abdominal or pelvic region.
  • Unexplained difficulties in passing urine or faeces.
  • suspected cancer (or cancer) in reproductive organs, bladder, rectum, or urinary tract.

• MRI Pelvis Specific Indications for Women:
  • Infertility
  • Irregular vaginal bleeding or Irregular menstruation showing no response after 2 months of conservative treatment.
  • Lumps or masses in your pelvic area (such as uterine fibroids).
  • Unexplained pain in your lower belly or pelvic area.

• MRI Pelvis Specific Indications for Men:
  • An undescended testicle.
  • Lumps in the scrotum or testicles.
  • Swelling in the scrotum or testicles.
  • Rarely to check prostate.

For Healthcare Providers:

• All MRI require pre-approval from NEXtCARE.
• Always submit detailed history of the sign & symptoms with onset and duration of the disease.

*Should not be coded in conjunction with 74712 & 74713.

References:

• https://www.healthline.com/health/pelvis-mri-scan
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5779565/df
• https://www.nhs.uk/conditions/mri-scan/
• https://www.msdmanuals.com/professional/neurologic-disorders/neurologic-tests-and-procedures/magnetic-resonance-imaging-mri-in-neurologic-disorders?query=MRI%20Brain
• https://www.pelvicpain.org.uk/diagnosis/imaging/mri/
• https://www.uwhealth.org/healthfacts/radiology/7670.pdf

For Members:

• What is MRI?
  • Magnetic resonance imaging (MRI) is a radiation-free, noninvasive, technique that uses strong magnetic fields to produce high quality, detailed and sectional images of the inside of the body in multiple planes.
  • MRI scanner is a large tube, open at both ends that contains powerful magnets, you lie on a flatbed that’s moved into the scanner tube.
  • An MRI scan is performed as an outpatient procedure; you are not required to stay in hospital overnight.
  • It is a painless and safe procedure; anaesthesia or sedation is not needed.
  • The magnetic fields and radio waves used during MRI scan are not harmful. Multiple Researches has confirmed that MRI scans are one of the safest medical procedures available.
  • MRI scans aren’t usually recommended for pregnant women.
  • If a scan is ordered to evaluate headache disorder, MRI with contrast is preferred over CT scan.

• What are the General Indications for MRI Cervical spine?
  • Fracture evaluation – following initial evaluation with (X-Ray or CT).
  • Abnormalities detected on other imaging studies.
  • Infections (Abscess, Discitis, Osteomyelitis).
  • Neck pain related with pinching of a nerve (radiculopathy).
  • Post-procedure evaluation.
  • Post-trauma.
  • Rheumatoid arthritis (for suspected cervical subluxation).
  • Multiple sclerosis and other white-matter diseases.
    • Initial diagnosis; OR
    • Periodic scans to assess asymptomatic progression in multiple sclerosis during the course of disease; OR
    • Tracking the progress of multiple sclerosis to establish a prognosis or evaluation of response to treatment; OR
    • To evaluate changes in neurologic signs and symptoms
  • Spinal cord infarct.
  • Severe scoliosis (curved spine)
  • Spondylo-arthropathies (following X-Ray and laboratory work-up).
  • Documented abnormality on neurological exam and has not previously been assessed and imaged or has progressed.
  • Worsening neck pain during a six (6) week course of therapy with at least two (2) different forms of treatment.

• What are the most common causes of neck pain?
  • Disk herniation.
  • Trauma
  • Prolonged use of laptop.
  • Poor posture.
  • Prolonged sitting.
  • Fracture(usually thoracic or lumbar).
  • Lumbar and cervical spinal stenosis.
  • Osteoarthritisthroughout the spine.
  • Spondylolisthesis.

For Healthcare Providers:

• All MRI require pre-approval from NEXtCARE.
• Always submit detailed history of the sign & symptoms with onset and duration of the disease.
• In case of trauma, kindly provide:
• Details of trauma (when, where and how).
• Neurological findings.
• If X-Ray is already done, please provide the report.
• In case without trauma, kindly provide:
• Onset and duration of the current condition.
• Conservative management provided, with duration and response.
• Complete physical examination and neurological findings.
• Signs and symptoms of severe radiculopathy or spinal stenosis.
• MRI can be approved for Neck pain with radiculopathy, if there is:
• Documented abnormality on neurological exam in a dermatome/radicular distribution that has not previously been imaged or has progressed since a prior imaging study has been performed.
• Lack of improvement or worsening during a six (6) week course of therapy with at least two (2) different forms of treatment.
• MRI can be approved for Neck pain without neurologic or radicular features, when both of the following criteria are met:
  • Lack of improvement or worsening during a six (6) week course of therapy with at least two (2) different forms of treatment.
  • Cervical spine X-ray is negative or does not clearly explain the cause of the patient’s symptoms.

References:

• https://aimspecialtyhealth.com/guidelines/PDFs/2017/Sept05/AIM_Guidelines_Spine.pdf
• https://www.nhs.uk/conditions/mri-scan/
• https://www.msdmanuals.com/professional/neurologic-disorders/neurologic-tests-and-procedures/magnetic-resonance-imaging-mri-in-neurologic-disorders?query=MRI%20Brain
• https://www.msdmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/neck-and-back-pain/evaluation-of-neck-and-back-pain?query=lumbar%20spine%20imaging

For Members:

• What is Bone Age Study?
  • As children grow, growth plates in their bones change in appearance on the X-ray images and become thinner, eventually disappearing. This is called “closed growth plates”.
  • A child’s bone age is called the skeletal age.
  • The growth plates look different at each age, a Physician can assign a bone age based on the appearance of the bones and growth plates.
  • Bone age studies can help to evaluate how fast or slowly a child’s skeleton is maturing, which can help doctors diagnose conditions that delay or accelerate physical growth and development.
  • Bone age can also be used to monitor children on growth hormone therapy or those presenting in delayed or advanced stages of puberty, requiring treatment.
  • Usually, the difference between a child’s bone age and his or her chronological age might indicate a growth problem, but not always. Sometimes perfectly healthy children can have bone ages that differ from their chronological ages
  • This test is usually ordered by Pediatricians or Pediatric Endocrinologists.
  • Children usually don’t have any signs or symptoms of diseases that affect growth. They tend to reach puberty (adulthood) later than their peers do, with delay in the onset of sexual development and the pubertal growth spurt.
  • Conventionally, Bone age is determined from an X-Ray of the left hand and can provide an estimate of remaining growth potential and help predict adult height.
  • The test is also used to monitor progress and guide treatment of kids with conditions that affect growth e.g. growth hormone deficiency.

• What are the General Indications for Bone Age Study?
  • Short Stature (Most Common)
  • Idiopathic Short Stature
  • Short Children born for small gestational age
  • Delayed Growth and Puberty for adolescent
  • Precocious (early) Puberty
  • Growth Hormone Deficiency
  • Turner Syndrome
  • Bone age can be used to predict:
    • how much time a child will be growing.
    • when a child will enter puberty.
    • what the child’s ultimate height will be.

What are the Special Indications for Bone Age Study?

1-Endocrine:

• Growth hormone deficiency (GHD)
• Constitutional delay
• Hypothyroidism
• Hypogonadism
• Cushing’s disease

2-Nutritional:

• Malnutrition
• Failure to gain weight as a result of disease
• Inadequate bone mineralization

3-Medications:

• Glucocorticoids
• Amphetamine
• Gonadotropin-releasing hormone (GnRH) analogues
• Aromatase Inhibitors

4-Chronic Disease:

• Coronary heart disease (CHD)
• Chronic Kidney disease (CKD)
• Juvenile idiopathic arthritis
• Inflammatory Bowel disease (IBD)
• Severe Asthma
• Cystic Fibrosis

5-Chromosomal Abnormalities:

• Trisomy 13, 18 and 21 Syndromes
• Turner Syndrome
• Klinefelter Syndrome
• Russel-Silver Syndrome

For Healthcare Providers:

• Always submit detailed history of the sign & symptoms with onset and duration.

References:

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4628949/
• https://pediatrics.aappublications.org/content/pediatrics/early/2017/11/13/peds.2017-1486.full.pdf
• https://pediatrics.aappublications.org/content/140/6/e20171486
• https://pediatrics.aappublications.org/content/pediatrics/104/Supplement_5/1036.full.pdf?ck=nck
• https://kidshealth.org/en/parents/xray-bone-age.html
• https://radiopaedia.org/articles/bone-age-assessment