RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA ......CABG Off Pump Without Iabp (S7F6.2) Coronary Angiography report & Video, 2D Echo X-Ray chest, Operation notes Post surgery photo (female

Sr.

No.Category Name of the Disease / Surgery

Mandatory documents at the time

of Preauth

Mandatory documents at

the time of Claim

1 BurnsAbove 60% Mixed Burns ( With

Surgeries) (S13N1.7)

Clinical photo of affected part diagramatic

distribution of burns mandatory(Rule of 9)Clinical photo of affected part

2 BurnsUp To -60% Mixed Burns( With

Surgeries) (S13N1.6)



3 BurnsUp to -40% With scalds (

conservative) (S13N1.1)


distribution of burns mandatory(Rule of 9)

Note that lessthan 30 % burns are covered by the

scheme

Clinical photo of affected part

4 Burns Upto-40% Mixed Burns( With surgeries) (S13N1.2)


distribution of burns mandatory(Rule of 9)

Note that lessthan 30 % burns are covered by the

scheme

Clinical photo of affected part

5 Burns Upto-50% with scalds(Conservative) (S13N1.3)Clinical photo of affected part diagramatic


6 Burns Up to -50% Mixed Burns( With surgeries) (S13N1.4Clinical photo of affected part diagramatic


7 BurnsUp to -60% With scalds (

conservative) (S13N1.5)



8 Burns

Post Burn contracture surgeries for functional improvement (Package

including splints pressure garments and Physiotherapy) - Mild

(S13N2.1)

Clinical photo of affected part Clinical photo of affected part

9 Burns


including splints pressure garments and Physiotherapy) - Moderate

(S13N2.2)


10 Burns


including splints pressure garments and Physiotherapy) - Severe

(S13N2.3)


11

Cardiac and

Cardiothoracic

Surgeries

Dissecting Aneurysms

(S7F11.6)CT Angio/2D Echo Post procedure Doppler, operation notes

12

Cardiac and

Cardiothoracic

Surgeries

Intrathoracic Aneurysm- Aneurysm Requiring Bypass (With Graft)

(S7F11.5)CT-ANGIO/ Coronary Angio Post procedure Doppler, operation notes

13

Cardiac and

Cardiothoracic

Surgeries

Intrathoracic Aneurysm- Aneurysm Not Requiring Bypass (With Graft)

(S7F11.4)CT-ANGIO Post procedure Doppler, operation notes

14

Cardiac and

Cardiothoracic

Surgeries

Aneurysm Resection & Grafting(S7F11.3) 2D ECHO, /CT- Angio Post procedure Doppler, operation notes

15

Cardiac and

Cardiothoracic

Surgeries

Coarctation Of Aorta Repair

Without Graft (S7F11.2)

2D ECHO /CT- Angio

AORTOGRAM IS NECESSARY.Post procedure Doppler, operation notes

16

Cardiac and

Cardiothoracic

Surgeries

Coarctation Of Aorta Repair

With Graft (S7F11.1)

2D ECHO /CT- Angio

AORTOGRAM IS NECESSARY.Post procedure Doppler, operation notes

17

Cardiac and

Cardiothoracic

Surgeries

Surgery-PDA (S7F13.16) 2D Echo 2D Echo, Operation notes

18

Cardiac and

Cardiothoracic

Surgeries

Intracardiac Repair Of Vsd

(S7F13.15)2D Echo 2D Echo, Operation notes

19

Cardiac and

Cardiothoracic

Surgeries

Surgery For Intracardiac

Tumours (S7F13.12)2D ECHO

2D ECHO/ Histopath , Post

surgery PHOTOGRAPH, Operation notes

SCAR PHOTO IS MANDATORY(female patients

may be made an exception)

20

Cardiac and

Cardiothoracic

Surgeries

Carotid Embolectomy

(S7F13.11)CT- Angio Doppler, Operation notes

21

Cardiac and

Cardiothoracic

Surgeries

Femoro-Femoral Bypass

Without Graft (S7F13.8)CT- Angio/ MRI Angio Doppler, Operation notes

22

Cardiac and

Cardiothoracic

Surgeries

Femoro-Femoral Bypass With

Graft (S7F13.7)CT- Angio/ MRI Angio Doppler, Operation notes

23

Cardiac and

Cardiothoracic

Surgeries

Femoroileal Bypass Without


24

Cardiac and

Cardiothoracic

Surgeries

Femoroileal Bypass With Graft

(S7F13.5)CT- Angio/ MRI Angio Doppler, Operation notes

25

Cardiac and

Cardiothoracic

Surgeries

Femoro Popliteal Bypass

Without Graft (S7F13.4)CT- Angio/ MRI Angio Doppler, Operation notes

26

Cardiac and

Cardiothoracic

Surgeries

Femoro Popliteal Bypass With


27

Cardiac and

Cardiothoracic

Surgeries

Total Correction Of Tetralogy

Of Fallots (S7F14.3)2D Echo 2D Echo, Operation notes

RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME

Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)

Sr.



of Preauth


the time of Claim

28

Cardiac and

Cardiothoracic

Surgeries

Systemic Pulmonary Shunts

Without Graft (S7F14.2)2D Echo 2D Echo, Operation notes

29

Cardiac and

Cardiothoracic

Surgeries

Systemic Pulmonary Shunts

With Graft (S7F14.1)2D ECHO 2D Echo, Operation notes

30

Cardiac and

Cardiothoracic

Surgeries

Mitral Valvotomy (Open) (S7F17.4) 2D Echo

2D Echo, Operation notes SCAR PHOTO IS

MANDATORY (female patients may be made

an exception)

31

Cardiac and

Cardiothoracic

Surgeries

Closed Mitral Valvotomy

(S7F17.3)2D Echo



an exception)

32

Cardiac and

Cardiothoracic

Surgeries

Open Pulmonary Valvotomy

(S7F17.2)2D Echo



an exception)

33

Cardiac and

Cardiothoracic

Surgeries

Sol Mediastinum (S7F18.5) CT-CHEST /X- RAY

Xray, Histopathology report, Operation notes

CLINICAL PHOTO DURING CLAIMS IS


an exception)

34

Cardiac and

Cardiothoracic

Surgeries

Lung Cyst (S7F18.4) CT-CHEST /X- RAY


CLINICAL PHOTO DURING CLAIMS IS


an exception)

35

Cardiac and

Cardiothoracic

Surgeries

Lobectomy (S7F18.2) CT-CHEST /X- RAY


CT/MRI & CLINICAL PHOTO DURING CLAIMS IS


an exception)

36

Cardiac and

Cardiothoracic

Surgeries

Pneumonectomy (S7F18.1) CT-CHEST /X- RAY


CT/MRI & CLINICAL PHOTO DURING CLAIMS IS


an exception)

37

Cardiac and

Cardiothoracic

Surgeries

Intracardiac Repair Of Asd

(S7F19.1)2D Echo

2D Echo, Operation notes CLINICAL PHOTO

DURING CLAIMS IS MANDATORY (female

patients may be made an exception)

38

Cardiac and

Cardiothoracic

Surgeries

Diaphragmatic Hernia

(S7F20.2)X-ray ,USG

Post procedure clinical photo, Xray, Operation

Notes CLINICAL PHOTO DURING CLAIMS IS


an exception)

39

Cardiac and

Cardiothoracic

Surgeries

Renal Angioplasty (S7F5.1) Angiography

Angioplasty Video, Stent stickers Claims

approval subject to stent visiblity and

restoration of arterial lumen in angioplasty

video.

40

Cardiac and

Cardiothoracic

Surgeries

Mitral Valve Replacement

(With Valve) (S7F6.4)2D Echo

Post procedure clinical photo, 2D Echo/ Xray

chest, operation notes sticker mandatory for

claim (female patients may be made an

exception for scar photo)

41

Cardiac and

Cardiothoracic

Surgeries

CABG With Aneurysmal Repair

(S7F6.3)Angiography

Post surgery PHOTOGRAPH / DOPPLER,

operation notes (female patients may be made

an exception for scar photo)

42

Cardiac and

Cardiothoracic

Surgeries

CABG Off Pump Without Iabp

(S7F6.2)Coronary Angiography report & Video, 2D Echo

X-Ray chest, Operation notes Post surgery photo

(female patients may be made an exception for

scar photo)

43

Cardiac and

Cardiothoracic

Surgeries

CABG On Pump Without Iabp

(S7F6.1)Coronary Angiography report & Video, 2D Echo


SCAR PHOTO IS MANDATORY DURING CLAIMS

(female patients may be made an exception for

scar photo)

44

Cardiac and

Cardiothoracic

Surgeries

Coronary Bypass Surgery Off

Pump With Iabp (S7F6.6)Coronary Angiography report & Video, 2D Echo


IN 2D ECHO EF SHOULD BE LESS THAN 40% IS

MANDATORY FOR PREAUTH IABP STICKER FOR

CLAIMS REQUIRED (female patients may be

made an exception for scar photo)

45

Cardiac and

Cardiothoracic

Surgeries

Coronary Bypass Surgery On

Pump With Iabp(S7F6.5)Coronary Angiography report & Video, 2D Echo


IN 2D ECHO EF SHOULD BE LESS THAN 40% IS

MANDATORY FOR PREAUTH. IABP STICKER FOR

CLAIMS REQUIRED (female patients may be

made an exception for scar photo)

46

Cardiac and

Cardiothoracic

Surgeries

Double Valve Replacement

(With Valve) (S7F9.3)2D ECHO

2D Echo/ Xray, Post surgery photo, bar code

sticker, Operation notes (female patients may

be made an exception for scar photo)

47

Cardiac and

Cardiothoracic

Surgeries

Tricuspid Valve Replacement

(S7F9.2)2D ECHO




48

Cardiac and

Cardiothoracic

Surgeries

Aortic Valve Replacement

(With Valve) (S7F9.1)2D ECHO




49

Cardiac and

Cardiothoracic

Surgeries

Carotid Artery Bypass With

Synthetic Graft (S7F9.17)

CT angio/ MRI-angio/ Color

Doppler/ ANGIOGRAM

COLOR DOPPLER, Operation Notes, Barcode

Sticker



Sr.



of Preauth


the time of Claim

50

Cardiac and

Cardiothoracic

Surgeries

Brachioradial Bypass With



Doppler/ ANGIOGRAM


Sticker

51

Cardiac and

Cardiothoracic

Surgeries

Femorodistal Bypass With



Doppler/ ANGIOGRAM


Sticker

52

Cardiac and

Cardiothoracic

Surgeries

Femorodistal Bypass With Vein

Graft (S7F9.12)


Doppler/ ANGIOGRAMCOLOR DOPPLER, Operation Notes

53

Cardiac and

Cardiothoracic

Surgeries

Axillo Bifemoral Bypass With



Doppler/ ANGIOGRAM


Sticker

54

Cardiac and

Cardiothoracic

Surgeries

Aorto Bi-illac - Bifemoral Bypass With Synthetic Graft (S7F9.10)CT angio/ MRI-angio/ Color

Doppler/ ANGIOGRAM


Sticker

55

Cardiac and

Cardiothoracic

Surgeries

Medium Size Arterial Aneurysms With Synthetic Graft (S7F9.9)CT angio/ MRI-angio/ Color

Doppler/ ANGIOGRAM


Sticker

56

Cardiac and

Cardiothoracic

Surgeries

Medium Size Arterial

Aneurysms - Repair (S7F9.8)


Doppler/ ANGIOGRAMCOLOR DOPPLER, Operation notes

57

Cardiac and

Cardiothoracic

Surgeries

Small Arterial Aneurysms - Repair (S7F9.7)CT angio/ MRI-angio/ Color

Doppler/ ANGIOGRAMCOLOR DOPPLER, Operation notes

58

Cardiac and

Cardiothoracic

Surgeries

D V T - Ivc Filter (S7F9.5) COLOR DOPPLER Post procedure Angio

59

Cardiac and

Cardiothoracic

Surgeries

A V Fistula At Elbow (S7F9.21) COLOR DOPPLER Clinical Photo/COLOR DOPPLER

60

Cardiac and

Cardiothoracic

Surgeries

A V Fistula At Wrist (S7F9.20) COLOR DOPPLER Clinical Photo/COLOR DOPPLER

61

Cardiac and

Cardiothoracic

Surgeries

Arterial Embolectomy

(S7F9.19)ANGIOGRAM/ COLOR DOPPLER

If peripheral embolectomy-

COLOUR DOPPLER AND PROCEDURE NOTES

ONLY FOR CLAIMS.If abdominal artery

embolectomy then CT angiogram required

62

Cardiac and

Cardiothoracic

Surgeries

Excision Of Av Malformation

Small (S7F9.18)

MRI ANGIOGRAM/SPIRAL CT

/ANGIOGRAMCOLOR DOPPLER, Operation notes

63

Cardiac and

Cardiothoracic

Surgeries

Excision Of Av Malformation

Large(S7F9.22)

MRI ANGIOGRAM/SPIRAL CT

/ANGIOGRAMCOLOR DOPPLER, Operation notes

64

Cardiac and

Cardiothoracic

Surgeries

Peripheral Embolectomy

Without Graft (S7F9.23)ANGIOGRAM/ COLOR DOPPLER COLOR DOPPLER, Operation notes

65

Cardiac and

Cardiothoracic

Surgeries

Vascular tumours (S7F9.6) Angiogram / Spiral CT COLOR DOPPLER / Scar Photo, Operation notes

66

Cardiac and

Cardiothoracic

Surgeries

Axillo brachial bypass using with synthetic graft (S7F9.14) Angiogram / Spiral CT COLOR DOPPLER / Scar Photo, Operation notes

67

Cardiac and

Cardiothoracic

Surgeries

Carotid Body tumours Excision

(S7F9.16)Angiogram / Spiral CT COLOR DOPPLER / Scar Photo, Operation notes

68

Cardiac and

Cardiothoracic

Surgeries

Surgery without CPB (S7F12.1) 2D Echo / Xray chest/ CT 2D Echo/Scar photo

69

Cardiac and

Cardiothoracic

Surgeries

Surgery with CPB (S7F12.2) 2D Echo / Xray chest/ CT 2D Echo/Scar photo

70

Cardiac and

Cardiothoracic

Surgeries

Pericardiostomy (S7F9.4) 2D Echo / CT 2D Echo/Scar photo

71

Cardiac and

Cardiothoracic

Surgeries

Percardectomy (S7F10.1) 2D Echo / CT 2D Echo/Scar photo

72

Cardiac and

Cardiothoracic

Surgeries

Pericardiocentesis (S7F10.2) 2D Echo / CT 2D Echo/Scar photo

73

Cardiac and

Cardiothoracic

Surgeries

Annulus aortic ectasia with valved conduits (S7F11.7) Angio / 2Decho/ CT 2D Echo/Scar photo

74

Cardiac and

Cardiothoracic

Surgeries

Aorto-aorto bypass with graft

(S7F13.1)Angio /CT angio/ MR angio Doppler, Operation notes/ Scar Photo

75

Cardiac and

Cardiothoracic

Surgeries

Aorto-aorto bypass without graft (S7F13.2) Angio /CT angio/ MR angio Doppler, Operation notes/ Scar Photo



Sr.



of Preauth


the time of Claim

76

Cardiac and

Cardiothoracic

Surgeries

TGA Arterial switch (S7F13.9) 2D Echo / Angio 2D Echo/Scar Photo

77

Cardiac and

Cardiothoracic

Surgeries

TGA Sennings Procedure

(S7F13.10)2D Echo / Angio 2D Echo/Scar Photo

78

Cardiac and

Cardiothoracic

Surgeries

Ruptured sinus of valsalva correction (S7F13.13) CAG / 2D Echo 2D Echo/Scar Photo

79

Cardiac and

Cardiothoracic

Surgeries

TAPVC correction (S7F13.14) 2D Echo/ CT 2D Echo/Scar Photo

80

Cardiac and

Cardiothoracic

Surgeries

Ross procedure Intracardiac repair of complex congenital heart with

special conduits (S7F16.1)2D Echo 2D Echo/Scar Photo

81

Cardiac and

Cardiothoracic

Surgeries

Ross procedure Intracardiac repair of complex congenital heart without

special conduits (S7F16.2)2D Echo 2D Echo/Scar Photo

82

Cardiac and

Cardiothoracic

Surgeries

Valve repair with Prosthetic ring (S7F13.17) 2D Echo 2D Echo/Scar Photo

83

Cardiac and

Cardiothoracic

Surgeries

Valve repair without Prosthetic ring (S7F17.1) 2D Echo 2D Echo/Scar Photo

84

Cardiac and

Cardiothoracic

Surgeries

Decortication (S7F18.3) CT Chest Clinical Photo / Xray

85

Cardiac and

Cardiothoracic

Surgeries

Thoracoplasty (S7F19.2) CT Chest Clinical Photo / Xray

86

Cardiac and

Cardiothoracic

Surgeries

Myoplasty (S7F19.3) CT Chest Clinical Photo / Xray

87

Cardiac and

Cardiothoracic

Surgeries

Transpleural BPF Closure

(S7F19.4)CT Chest Clinical Photo / Xray

88

Cardiac and

Cardiothoracic

Surgeries

Diaphragmatic Eventeration

(S7F20.1)Barium studies / CT scan Clinical Photo / Xray

89

Cardiac and

Cardiothoracic

Surgeries

Oesophageal diverticula/ Achlasia cardia (S7F20.3) Barium studies / CT scan USG /Scar Photo

90

Cardiac and

Cardiothoracic

Surgeries

Thoracotomy, Thoraco abdominal approach (S7F21.1) CT Scan Clinical Photo with scar

91

Cardiac and

Cardiothoracic

Surgeries

Bronchial Foreign Body Removal With Scope(S7F22.1) Broncoscopy / CT scan Post Procedure Endoscopic Picture

92

Cardiac and

Cardiothoracic

Surgeries

Bronchial Injuries Due To Foreign Body Repair Surgery (S7F22.2) Broncoscopy / CT scan Post Procedure Endoscopic Picture

93

Cardiac and

Cardiothoracic

Surgeries

Gastro study followed by Thoracotomy and repairs for Oesophageal

injury for corrosive injuries/FB (S7F23.1)Gastroscopy Post procedure endoscopic picture

94

Cardiac and

Cardiothoracic

Surgeries

Surgery without graft for arterial injuries, venous injuries (S7F24.1) Angiogram /Doppler/ CT angio Clinical Photo with scar

95

Cardiac and

Cardiothoracic

Surgeries

Vascular injury in upper limbs- Axillary, Brachial, Radial and Ulnar repair

with vein graft (S7F24.2)Angiogram /Doppler/ CT angio Doppler / Scar Photo

96

Cardiac and

Cardiothoracic

Surgeries

Major Vascular Injury in Lower

Limbs repair (S7F24.3)Angiogram /Doppler/ CT angio Doppler / Scar Photo

97

Cardiac and

Cardiothoracic

Surgeries

Minor Vascular Injury repair- tibial vessels in leg (S7F24.4) Angiogram /Doppler/ CT angio Doppler / Scar Photo

98

Cardiac and

Cardiothoracic

Surgeries

Minor Vascular Injury repair- Vessels in foot (S7F24.5) Angiogram /Doppler/ CT angio Doppler / Scar Photo

99

Cardiac and

Cardiothoracic

Surgeries

Surgery with Vien Graft

(S7F24.6)Angiogram /Doppler/ CT angio Doppler / Scar Photo

100

Cardiac and

Cardiothoracic

Surgeries

Vascular Injury Repair With

Prosthetic Graft (S7F24.7)Angiogram /Doppler/ CT angio Doppler / Scar Photo

101

Cardiac and

Cardiothoracic

Surgeries

Neck Vascular Injury- Carotid

Vessels (S7F24.8)Angiogram /Doppler/ CT angio Doppler / Scar Photo

102

Cardiac and

Cardiothoracic

Surgeries

Abdominal Vascular Injuries- Aorta, Iliac arteries, IVC, Iliac Veins




Sr.



of Preauth


the time of Claim

103

Cardiac and

Cardiothoracic

Surgeries

Thoracic Vascular Injuries


104 CardiologyAngioplasty With Stent

(M7F1.3)Coronary Angiography report & Video




video.

105 Cardiology Ptca Additional Stent (M7F1.2) Coronary Angiography report & Video




video.

106 CardiologyCoronary Ballon Angioplasty

(M7F1.1)Coronary Angiography report & Video




video.

107 CardiologyTemporary Pacemaker

Implantation (M7F3.2)

ECG with date & name of patient

(preferably printed)Post procedure clinical photo, ECG

108 CardiologyPermanent Pacemaker

Implantation (M7F3.1)


(preferably printed)

Post procedure clinical photo,ECG, X-Ray chest/

Fluoroscopic Image

109 CardiologyPericardial Effusion

Tamponade (M7T1.10)2D ECHO 2D Echo,Lab Investigations Of Pericardial Fluid

110 Cardiology Simple Arrhythmias (M7T1.9)ECG with date & name of patient


Clinical notes, ECG Focus ABLATION IF DONE,

THEN PROCEDURE NOTES ARE mandatory for

claims

111 CardiologyComplex Arrhythmias

(M7T1.8)



Clinical notes, ECG Cartoguided ABLATION IF

DONE, THEN PROCEDURE NOTES ARE

Mandatory for claims

112 Cardiology Pulmonary Embolism (M7T1.7) Doppler, CT Pul angio/ angio,ECG , Clinical notes, CT Pulm Angio is

mandatory at the time of claim.

113 CardiologyInfective Endocarditis

(M7T1.6)ECG, 2D Echo, CBC, ESR

Post procedure evidence of clinical

improvement & ECG, Lab investigations, Blood

culture (can be negative)

114 CardiologyRefractory Cardiac Failure

(M7T1.5)

ECG, 2D Echo, CXR ,CPK & Trop T required at the

time preauth, Patient has to be certified by

cardiologist/Physician for the same at the time of

preauth.

ECG, 2D Echo,Evidence of treatment resulting in

refractory cardiac failure,

115 CardiologyAcute Mi Requiring Iabp Pump

(M7T1.4)TROPONIN, ECG, CPKMB, 2D Echo, Clinical notes

Lab investigations, Clinical notes IABP sticker

mandatory at the time of claim.

116 CardiologyAcute Mi With Cardiogenic

Shock (M7T1.3)

ECG with date & name, Cardiac

Enzymes, Clinical NotesLab investigations, Clinical notes

117 CardiologyThrombolytic thearpy for

Acute Mi (M7T1.1)Serial ECG with date & name, Cardiac Enzymes Lab investigations, Clinical notes

118 CardiologyCoil Closure Multiple Coils

(S7F1.8)2D ECHO

Fluoroscopy Image/ Video fluroscopy videos, ot

notes, stickers as and where applicable

119 CardiologyCoil Closure Single Coil

(S7F1.7)2D ECHO



120 Cardiology PDA Device Closure (S7F1.6) 2D ECHOFluoroscopy Image/ Video fluroscopy videos, ot


121 Cardiology VSD Device Closure (S7F1.4) 2D ECHOFluoroscopy Image/ Video fluroscopy videos, ot


122 Cardiology ASD Device Closure (S7F1.3) 2D ECHOFluoroscopy Image/ Video fluroscopy videos, ot


123 Cardiology PDA Stenting (S7F1.5) 2D ECHOFluoroscopy Image/ Video fluroscopy videos, ot


124 CardiologyBalloon Atrial Septostomy

(S7F2.2)2D ECHO



125 Cardiology Balloon Valvotomy (S7F2.1) 2D EchoFluoroscopy Image/ Video fluroscopy videos, ot


126 CardiologyCoarctation Of Aorta Repair

Without Stent (S7F4.2)

2D ECHO /CT angio/ angio,

aortogram at the time of preauthFluoroscopy Image/ Video

127 CardiologyCoarctation Of Aorta Repair

With Stent (S7F4.1)

2D ECHO /CT angio/ angio,

aortogram at the time of preauth

Fluoroscopy Image/ Video, sticker mandatory

for claim, Claims approval subject to stent

visiblity and restoration of arterial

lumen in angioplasty video.

128 Cardiology Peripheral Angioplasty(S7F5.2) Angiography

Angioplasty Video, Stent stickers, Claims



video.

129 Cardiology Vertebral Angioplasty (S7F5.3) Angiography

Angioplasty Video, Stent stickers,

Claims approval subject to stent visiblity and


video.



Sr.



of Preauth


the time of Claim

130 Critical Care Septic Shock(Icu Management) With Ventilatory Assistance (M3Q1.8)

Machine generated ABG, RFT, USG, Urine R/M,

Clinical photograph, Xray chest, CBC.Justification

from treating Physician for necessity of

ventilatory support if SpO2 is

>80%, esp. of no evidence of alkalosis/acidosis

ABG, Lab Investigations, Post treatment

evidence of clinical improvement, report of

Blood culture/ Urine culture If blood culture

report is negative then other markers of sepsis

like Urine culture , sputam culture, C3

marker,csf ananlysis to be given to confirm the

dignosis septic shock

131 Critical CareOp Poisoning Requiring Ventilatory Assistance Clinical Photo - 1 Week

Stay (M3Q1.7)

Clinical photo on ventilator, RFT, Machine

generated ABG, Sr cholinesterase


evidence of clinical improvement

132 Critical CareARDS Plus DIC (Blood & Blood Products) With Ventilatory Care

(M3Q1.6)

Chest X-Ray, Machine generated ABG, Clinical

photo with ventilator support, CBC, DIC profile



133 Critical CareARDS With Multi Organ Failure With Ventilatory Care 14 Days Stay

(M3Q1.5)

Chest X-Ray/ HRCT Chest, Machine generated

ABG, Clinical photo, RFT, LFT, CBC, Sr Electrolites

For ARDS packages Ventilator with NIV Mask /

invasive ventilator should be discretion of

treating physician

ABG, Lab Investigations(CBC, LFT, RFT), Post

treatment evidence of clinical improvement.

Justification from treating dr for standalone

NIV treatment(if given) in ARDS

134 Critical CareARDS With Ventilatory Care 14

Days Stay(M3Q1.4)


ABG, Clinical photo with Ventilatory support,

For ARDS packages Ventilator with NIV Mask /

invasive ventilator should be discretion of

treating physician, CPAP, BiPAP is not accepted



135 Critical CareAcute Bronchitis And Pneumonia With Respiratory Failure, Ventilator

10 Days Stay (M3Q1.3)


ABG, Clinical photo with ventilatory support,



136 Critical Care

COPD - Respiratory Failure

(Infective Exacerbation)14

Days Stay (M3Q1.2)

Chest X-Ray/ HRCT Chest/ Spirometry, Clinical

photo, , Machine generated ABG

ABG, Lab Investigations, X-

ray, Post treatment evidence of clinical

improvement

137 Critical Care

Acute Severe Asthma With

Acute Respiratory Failure 10

Days Stay(M3Q1.1)

Machine generated ABG, Clinical Photo with

ventilator support, Chest X-Ray

ABG, Lab Investigations, X- ray, Post treatment


138 DermatologyToxic Epidermal necrolysis

(M11T5. 1)

Urine R/M, CBC, LFT, RFT, Skin

SwabClinical notes, CBC, LFT, RFT, Skin Biopsy

139 DermatologyStevens Johnson Syndrome

(M11T5. 2)

Urine R/M, CBC, LFT, RFT, Skin

SwabClinical notes, CBC, LFT, RFT, Skin Biopsy

140 Dermatology Pemphigus/ Pemphigoid Tzanck clinical protocol (M11T5. 3) Tzanck Smear, Serum DSG 1& 3 Clinical notes, Skin Biopsy

141 EndocrinologyPyelonephritis 10 days stay

(M13U2.4)Urine R/M, USG

Post procedure Evidence of clinical imrovement

, LAB INVESTIGATIONS, Urine C/S

142 Endocrinology Lower Respiratory tract infection (M13U1.1)10 Days Stay CXR, Sputum gram stain Post Procedure Evidence Of Clinical

Imrovement , Lab Investigations

143 Endocrinology Fungal sinusitis PNS 10 Days (M13U1. 2)

CT PNS, Direct microscopy report

to confirm Fungal hyphae is mandatory during

preauth

Post Procedure Evidence Of Clinical


144 Endocrinology Cholecystitis Abd 10 Days Stay (M13U1.3) USG /CT Abd, LFT Post Procedure Evidence Of Clinical


145 EndocrinologyCavernous sinus thrombosis

10 Days Stay (M13U1.4)MRI, Venogram



146 EndocrinologyRhinocerebral mucormycosis

10 Days Stay(M13U1.5)

CT-Scan, (Brain PNS Chest) when necessary,

Direct microscopy report for Fungal hyphae is

mandatory during preauth.



147 Endocrinology Hypopitutarism 1 Week Stay (M13U1.6)

T3 T4 TSH, basal cortisol post-ACTH cortisol, GH

stimulation test, FSH, LH, Testosterone or Estradiol

GH stimulation test 1 yr. needed MRI pic visual

field water deprivation test 1 yr. needed

Post Procedure Evidence Of Clinical, Lab

Investigations, Injection Vial With Patient Name

On It And Bills Of The Injection Are Mandatory

For Claims

148 EndocrinologyPituitary – Acromegaly 1 Week Stay

(M13U2.1)

Post glucose GH assay, prolactin, t3 t4 TSH, Basal

cortisol cost ACTH, FSH / LH, testosterone / estriol,

water deprivation test (if needed)

Post Procedure Evidence Of Clinical, Lab

Investigations

149 EndocrinologyCUSHINGs Syndrome

(M13U2.2)

Cortisol assay after dexamethasone, ACTH assay,

DHEAS, MRI pituitary CT Abd, Dexa of Hip spine

Post procedure Evidence of clinical, LAB

INVESTIGATIONS

150 EndocrinologyDelayed Puberty Hypogonadism (ex.Turners synd, Kleinfelter synd)

(M13U2.3)

FSH, LH, testosterone, estradiol, USG pelvis,

karyotyping, T4 TSH, Xray bone age, X-ray skull,

MRI brain DEXA, 2D echo

Post procedure Evidence of clinical, LAB

INVESTIGATIONS

151 ENT SurgeryAdenoidectomy - Gromet

Insertion (S2B2.6)X-RAY NASOPHARYNX Post procedure clinical photograph

152 ENT SurgeryParapharyngeal Tumour

Excision (S2B2.5)CT- SCAN /MRI SCAN, FNAC BIOPSY,Post procedure clinical photograph

153 ENT Surgery Excision Of Tumours In Pharynx (S2B2.4) FNAC/biopsy, CT Scan Histopath report

154 ENT SurgeryExcision Of Benign Tumour

Nose (S2B3.5)CT PNS, DNE Post procedure clinical photograph

155 ENT Surgery Tympanoplasty (S2B3.3) AudiometryIntra OP Photo Post OP Pure Tone Audiometry

is required

156 ENT Surgery Mastoidectomy (S2B3.2) X-Ray/CT Temporal bone Post procedure clinical photograph

157 ENT SurgeryEndoscopic Sinus Surgery

(S2B3.1)CT PNS,DNE PHOTO GRAPH ENDOSCOPIC PHOTOGRAPH/ Sketch

158 ENT Surgery Bronchoscopic Foreign Body Removal (S2B4.1) RELEVANT X-RAYPost procedure clinical photograph, Post Op

Xray



Sr.



of Preauth


the time of Claim

159 ENT SurgeryBehind The Ear Analogue

Hearing Aid (S2P1.1)machine generated Audiometry

Clinical photo(10% of the

cases will be reinvestigated

in Government hospitals for Audiometry after

discharge)

160 ENT Surgery labyrinthectomy (S2B1.1) CT Scan PTI, IA Clinical photo

161 ENT SurgeryFacial nerve Decompression

(S2B1.2)CT Scan Clinical photo

162 ENT SurgeryTemporal Bone Excision

(S2B1.2)CT scan/ MRI Clinical photo

163 ENT SurgeryMicrolaryngeal Surgery

(S2B2.1)Nasal Endoscopy Clinical photo

164 ENT Surgery Phono Surgery for Vocal cord paralysis (S2B2.2) CT scan/ MRI Clinical photo

165 ENT Surgery Laryngo Fissurectomy (S2B2.3) CT scan Clinical photo

166 ENT SurgeryUvulo-Palato Pharyngoplasty

(S2B2.7)Polysomnography, CT/MRI Clinical photo

167 ENT SurgeryStapedectomy + Veingraft

(S2B3.4)

CT Temporal Bone, PTA, Impedance

audiometryClinical photo with Piston

168 ENT Surgery Angiofibroma Nose (S2B3.6) CT PNS, DNE Clinical photo

169 ENT Surgery Endoscopic DCR (S2B3.7) Clinical photo Clinical photo

170 GastroenterologyOesophageal Perforation- 7

Days Stay (M14V1.2)CT SCAN THORAX and Abdomen CT- ABDOMEN optional

171 Gastroenterology Biliary Stricture 3) Sclerosing Cholangitis 7 Days Stay (M14V1.18)MRCP/ ERCP, Per cutaneous Transhepatic/

Endoscopic Billiary Drainage, , USG

Post treatment evidence of radiological and

endoscopic image/ video

172 GastroenterologyBiliary Structure 2) Post Op

Leaks 7 Days Stay (M14V1.17)

MRCP/ ERCP, Per cutaneous Transhepatic Billiary/

Endoscopic Drainage, USG

ENDOSCOPIC IMAGE/ video

RADIOLOGICAL

173 GastroenterologyBiliary Structure 1) Post Op

Stent 7 Days Stay (M14V1.16)

MRCP/ ERCP, Per cutaneous Transhepatic Billiary/

Endoscopic Drainage, USG

ENDOSCOPIC IMAGE/ video

RADIOLOGICAL

174 Gastroenterology Cirrhosis With Hepatic Encephalopathy -11 Days Stay (M14V1.14)USG / ascitic fluid analysis, LFT, Sr Ammonia, PT-

INR, UGI Endoscopy(optional)

Post procedure clinical photograph and lab

invistigations, (LFT)

175 GastroenterologyObscure GI Bleed1 Week Stay

(M14V1.13)

CAPSULE ENDOSCOPY/ CT enterography/ Barium

Meal Follow Through, ENTEROSCOPY BIOPSY

(optional)

ENDOSCOPIC PHOTOGRAPH/ Lab investigations

176 Gastroenterology Chronic Pancreatitis With Severe Pain - 7 Days Stay (M14V1.12)CT Scan abdomen/ USG/ EUS / ERCP/ MRCP

RBS, Etiology of pancreatitis,LFT,RFT

post treatment Lab investigation WBC Count,Sr.

Amylase, Lipase which are repeated at an

interval of 48 hours of admission,LFT : esp.

AST,Blood Sugar Level,RFT: Urea & Creatinine

level,Sr Calcium level,USG Abdomen /CT Scan

Abdomen,APACHE Score at time of admission

& 48 hrs post admission,Diet Chart

177 Gastroenterology Acute Pancreatitis With Pseudocyst (Infected) 3 Weeks Stay(M14V1.11)S. AMYLASE, Sr Lipase, EUS/ CT- ABDOMEN, USG,

CBC

LAB INVESTIGATIONS(S. AMYLASE/ Sr Lipase),

USG

178 GastroenterologyAcute Pancreatitis (Severe) -3

Weeks Stay(M14V1.10)

CT Abdomen/ EUS, Sr AMYLASE, Sr Lipase, LFT,

electolytes , RANSON Scoring/ BISAP Scoring, RFT,

RBS, Etiology of pancreatitis

Post Treatment Evidence Of Usg. Lab

Investigation ( Sr. Amylase/Sr. Lipase ) Wbc

Count,Sr. Amylase, Lipase Which Are Repeated

At An Interval Of 48 Hours Of Admission,Lft :

Esp. Ast,Blood Sugar Level,Rft: Urea &

Creatinine Level,Sr Calcium Level,Usg Abdomen

/Ct Scan Abdomen, Ranson/Bisap Score At Time

of Admission ,Diet Chart

179 GastroenterologyAcute Pancreatitis (Mild) - 1

Week Stay With Post Treatment Evidence Of (M14V1.9)

CT Abdomen/ EUS, Sr AMYLASE, Sr Lipase, LFT,

electolytes , RANSON Scoring/ BISAP Scoring, RFT,

RBS, Etiology of pancreatitis

Post Treatment Evidence Of Usg. Lab

Investigation ( Sr. Amylase/Sr. Lipase ) Wbc

Count,Sr. Amylase, Lipase Which Are Repeated

At An Interval Of 48 Hours Of Admission,Lft :

Esp. Ast,Blood Sugar Level,Rft: Urea &

Creatinine Level,Sr Calcium Level,Usg Abdomen

/Ct Scan Abdomen,Ranson/Bisap Score At Time

Of Admission ,Diet Chart

180 GastroenterologyGastric Varices 3 Days Stay

(M14V1.8)UGI ENDOSCOPY ENDOSCOPIC PHOTOGRAPH

181 Gastroenterology Oesophageal Varices, Sclerotherapy- One Day Stay (M14V1.5) UGI ENDOSCOPY ENDOSCOPIC PHOTOGRAPH

182 GastroenterologyCorrosive Oesophageal injury

(M13V1.20)clinical history of acid ingestion

post treatment evidence of

Barium swallow / UGI scopy optional, MLC

183 GastroenterologyOesophageal foreign body

(M13V1.1)X-Ray


Endoscopic Photograph

184 Gastroenterology Achalasia cardia (M13V1.3) UGI endoscopy / Barium swallowpost treatment evidence of

Endoscopic Photograph/ Barium Swallow

185 Gastroenterology Oesophageal Varices, variceal banding (M13V1.4) UGI endoscopypost treatment evidence of


186 Gastroenterology Oesophageal Fistula (M13V1.6) CT Thoraxpost treatment evidence of

Photograph of stent in position

187 GastroenterologyGAVE (Gastric Antral Vascular

Ectasia) (M13V1.7)UGI Endoscopy



188 Gastroenterology Cirrhosis with hepato renal syndrome (M13V1.15)Reports of Serum Chemistry USG/CT ABDOMEN IS

MANDATORY AT TIME OF PREAUTH


Lab Investigation



Sr.



of Preauth


the time of Claim

189General

Medicine

Thrombocytopenia With

Bleeding Diathesis (M16Q1.1)CBC (platelet count), PT INR, BT, CT Post procedure Evidence of clinical imrovement

190General

Medicine

Haemophilia treatment with IV FPP, Factor VIII /Cryoprecipitate

(M16Q1.2)

VON WILL BRANDS / FACTOR VIII/ IX ASSAY

Coagulation Parameters


Imrovement , Case Sheet With Records Of

Factor Given

191General

Medicine

Metabolic Coma Requiring

Ventilatory Support (M16Q1.9)

Machine generated ABG, ECG, Blood Urea, Blood

sugar, Sr. Creat, Sr. Electrolites, LFT, clinical photo

with ventilatory support

Post treatment evidence of clinical

improvement, Vit B12 level / Lab investigations

192General

Medicine

Scorpion Sting Requiring

Ventilator Support (M16Q1.8)Serial ABG, Serial blood sugar, ECG


improvement & RFT investigations

193General

Medicine

Snake Bite Requiring Ventilator

Support (M16Q1.7)

Serial ABG, Serial blood sugar, ECG, PT/PTTK/ DIC

profile RFT


improvement & CPK, Lab investigations

194General

MedicineTb Meningitis (M16Q1.6)

CT Scan-Brain, CSF Analysis, Chest

X-Ray


improvement & Lab investigations, CSF

195General

MedicineCerebral Malaria (M16Q1.5)

Test for detection of Malarial

Parasite/ Rapid test, CBC,


improvement & Lab investigations

196General

Medicine

Chelation Therapy For

Thalassemia (M16Q1.4)Haemogram, Hb Electrophoresis, Serum Ferritin


improvement & LFT, Lab investigations

197General

Medicine

Other Coagulation Disorders with Von Wili Brand Factor: treatment

with IV FPP, Factor VIII /Cryoprecipitate (M16Q1.3 )Von Willi Brands Factor, Coagulation Parameters


Imrovement, Fdp(Fibrin Degradation Products)

Levels, Lab Investigations

198 General surgeryExcision Of Thyroglossal Cyst

Fistula (S1A1.19)CLINICAL PHOTOGRAPH, USG

Histopath report,Post procedure clinical

photograph

199 General surgery Parathyroidectomy (S1A1.18) USGHistopath report,Post procedure clinical

photograph

200 General surgeryCystic Hygroma Excision-Minor

(S1A1.16)CLINICAL PHOTOGRAPH


photograph

201 General surgeryCystic Hygroma Excision-Major



photograph

202 General surgery Wedge Excision (S1A1.14) CLINICAL PHOTOGRAPH Histopath report

203 General surgery Cystic Hygroma Excision- Extensive (S1A1.10) USG,CLINICAL PHOTOGRAPHHistopath report,Post procedure clinical

photograph

204 General surgery Partial Glossectomy (S1A1.9) BIOPSY, CLINICAL PHOTOGRAPHHistopath report,Post procedure clinical

photograph

205 General surgery Hemimandibulectomy (S1A1.6) X- RAY Clinical Photo, X- RAY, biopsy

206 General surgeryBranchial Sinus Excision



photograph

207 General surgeryRemoval Of Submandibular

Salivary Gland (S1A1.3)CLINICAL PHOTOGRAPH


photograph

208 General surgery Brachial Cyst Excision (S1A1.1) CLINICAL PHOTOGRAPHHistopath report,Post procedure clinical

photograph

209 General surgeryOperation For Hydatid Cyst

Liver (S1A10.1)USG/CT Histopathology report

210 General surgeryPortocaval Anastomosis

(S1A10.2)MRI/ USG/ UGI ENDOSCOPY ENDOSCOPY/ USG

211 General surgery Repair Of CBD (S1A11.7) CT/USG, LFT USG Post procedure clinical photograph

212 General surgery Cystogastrostomy (S1A11.6) CT/USG, LFT

Post procedure clinical photograph,USG

intra op photographic e/o surgery mandatory

for claim

213 General surgery Cystojejunostomy (S1A11.5) CT/USG, LFT

Post procedure clinical photograph,USG

intra op photographic e/o surgery mandatory

for claim

214 General surgeryLap Cholecystostomy With

Exploration CBD (S1A11.4)CT/USG, LFT


& Lab investigations, USG

post op HP for claim

215 General surgery Cholecystectomy & Exploration CBD (S1A11.3) CT/USG, LFT Post procedure clinical photograph,USG

216 General surgeryLap.Cholecystectomy

(S1A11.2)CT/USG, LFT

Post procedure clinical Potograph,VIDEO,USG

post op HP for claim

217 General surgery Cholecystectomy (S1A11.1) CT/USG, LFTPost procedure clinical

photograph,USG post op HP for claim

218 General surgerySplenectomy For

Hypersplenism (S1A13.1)CT/USG, PERIPHERAL SMEAR

Post procedure clinical

photograph,histopathology report

219 General surgery Colostomy Closure (S1A14.8)CLINICAL PHOTOGRAPH, Barium

StudyPost procedure clinical photograph

220 General surgery Colostomy (S1A14.7) USG/ CT, ENDOSCOPY/ Sketch Post procedure clinical photograph

221 General surgery Total Colectomy (S1A14.6)BARIUM, USG/ CT, ENDOSCOPY/

SketchPost procedure clinical photograph,BIOPSY

222 General surgeryOperation For Volvulus Of

Large Bowel (S1A14.2)CT-CONTRAST, X-RAY ABDOMEN X- RAY/Post procedure clinical photograph

223 General surgeryMal-Rotation & Volvulus Of

The Midgut (S1A14.1)CT, X-RAY ABD X- RAY/Post procedure clinical photograph

224 General surgery Total Thyroidectomy (S1A2.6) Thyroid Function Test, FNAC/USGHistopath report,Post procedure clinical

photograph

225 General surgerySubtotal Thyroidectomy

(S1A2.5)FNAC/ USG, T F T


photograph

226 General surgery Resection Enucleation (S1A2.4)FNAC , T F T , USG/ Thyroid

Scan(optional)BIOPSY,Post procedure clinical photograph

227 General surgery Simple Mastectomy(Nm) (S1A3.1) MAMMOGRAPHY, FNAC BIOPSY, Post procedure clinical photograph

228 General surgeryVentral And Scar Hernia With

Mesh (S1A4.9)CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph

229 General surgery Scar Hernia Without Mesh (S1A4.8) CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph



Sr.



of Preauth


the time of Claim

230 General surgeryUmbilical Hernia Hernia With


231 General surgeryUmbilical Hernia Without


232 General surgery

Rare Hernias

(Spigalion,Obuturator, Sciatic)

(S1A4.5)

CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph

233 General surgeryHiatus Hernia Repair

Abdominal (S1A4.4)USG ABDOMEN, UGI ENDOSCOPY/ Sketch Post procedure clinical photograph

234 General surgery Femoral Hernia (S1A4.3) CLINICAL PHOTOGRAPH Post procedure clinical photograph

235 General surgeryEpigastric Hernia With Mesh

(S1A4.2)CLINICAL PHOTOGRAPH, Post procedure clinical photograph

236 General surgeryEpigastric Hernia Without

Mesh (S1A4.1)CLINICAL PHOTOGRAPH, Post procedure clinical photograph

237 General surgeryAppendicular Perforation

(S1A5.2)X-ray Abdomen, USG

BIOPSY, Post procedure clinical photograph, Pus

C/S

238 General surgery Lap. Appendectomy (S1A5.1) USG Histopath,video,clinical photo

239 General surgeryHighly Selective Vagotomy

(S1A7.1)ENDOSCOPY/ Sketch Post procedure clinical photograph

240 General surgery Gastrostomy Closure (S1A7.10) CLINICAL PHOTOGRAPH Post Procedure Clinical Photograph

241 General surgery Duodenal Perforation (S1A7.2) USG/ CT- ABDOMEN, X-RAY Post procedure clinical photograph

242 General surgerySelective Vagotomy Drainage


243 General surgeryVagotomy Pyloroplasty


244 General surgery Gastrojejunostomy & Vagotomy (S1A7.5) ENDOSCOPY-VIDEO PHOTO/ Sketch Post procedure clinical photograph

245 General surgeryOperation For Bleeding Peptic

Ulcer (S1A7.6)ENDOSCOPY/ Sketch Post procedure clinical photograph

246 General surgeryPartial/Subtotal Gastrectomy

For Ulcer (S1A7.7)ENDOSCOPY/ Biopsy / Barium meal Post procedure clinical photograph

247 General surgery Pyloromyotomy (S1A7.8) ENDOSCOPY / Sketch Post procedure clinical photograph

248 General surgery Gastrostomy (S1A7.9) BIOPSY,USG, ENDOSCOPY/ Sketch Post procedure clinical photograph

249 General surgery Intussusception (S1A8.1) X-RAY ABD, USG / CT abd Post procedure clinical photograph, BIOPSY

250 General surgeryOperation For Acute Intestinal

Obstruction (S1A8.2)X-RAY ABD, USG / CT abd Post procedure clinical photograph, BIOPSY

251 General surgeryOperation For Acute Intestinal

Perforation (S1A8.3)X-RAY ABD, USG / CT abd Post procedure clinical photograph, BIOPSY

252 General surgeryOperation For Haemorrhage

Of The Small Intestine (S1A8.4)CT WITH CONTRAST Post procedure clinical photograph, BIOPSY

253 General surgeryOperations For Recurrent Intestinal Obstruction (Noble Plication Other)

(S1A8.5)CT-CONTRAST / USG, Xray Post procedure clinical photograph, BIOPSY

254 General surgeryResection & Anastomosis Of

Small Intestine (S1A8.6)CT/ USG, X-RAY ABD Post procedure clinical photograph, BIOPSY

255 General surgery Ileostomy (S1A8.7) CT abd / USG Post procedure clinical photograph, HP Report

256 General surgery Ileostomy Closure (S1A8.8) CLINICAL PHOTOGRAPH Post procedure clinical photograph

257 General surgeryPull Through Abdominal

Resection (S1A9.1)CLINICAL PHOTOGRAPH

Post procedure clinical photograph, Rectal

Biopsy

258 General surgery Anterior Resection (S1A9.2)BIOPSY, COLONOSCOPY, CLINICAL

PHOTOGRAPHPost procedure clinical photograph, BIOPSY

259 General surgery Cervical Rib excision (S1A1.2) Color Doppler , X-RAY Post procedure evidence of X-Ray

260 General surgery Parotid Duct repair (S1A1.4) Silography Post procedure evidence of Silography

261 General surgery Abbe Operation (S1A1.11) CLINICAL PHOTOGRAPH Post procedure clinical photograph

262 General surgery Segmental Mandible Excision (S1A1.7) X- RAY Clinical Photo, X- RAY

263 General surgeryCarotid Body-tumours

Excision (S1A1.8)Clinical Photograph , USG Neck/ Color doppler

Post procedure evidence of Clinical Photograph,

Biopsy

264 General surgery Vermilionectomy (S1A1.12) CLINICAL PHOTOGRAPH Post procedure clinical photograph

265 General surgery Wedge Excision & Vermilionectomy (S1A1.13) CLINICAL PHOTOGRAPHHistopath report,Post procedure clinical

photograph

266 General surgery Hemithyroidectomy (S1A2.1)FNAC , T F T , USG, Thyroid

Scan(optional)


photograph

267 General surgery Isthmectomy (S1A2.2)FNAC , T F T , USG, Thyroid

Scan(optional)


photograph

268 General surgery Partial Thyroidectomy (S1A2.3)FNAC , T F T , USG, Thyroid

Scan(optional)


photograph

269 General surgeryExcision of Lingual Thyroid

(S1A1.20)Clinical Photograph , Isotope Scan


photograph

270 General surgery Operation of the Duplication of the intestines (S1A14.3) CT-Contrast/ USG Post procedure evidence of Clinical photograph

271 General surgery Right Hemi Colectomy (S1A14.5)Barium / CT , Endoscopy , Biopsy,

USG

Post procedure evidence of Clinical

photograph/Biopsy

272 General surgery Left Hemi Colectomy (S1A14.4)Barium / CT , Endoscopy , Biopsy,

USG

Post procedure evidence of Clinical

photograph/Biopsy

273 General surgery Operation on Adrenal glands, unilateral for tumour (S1A12.2) Biochemical Investigations , CT , USG Post procedure evidence of USG,Biopsy

274 General surgery Operation of Adrenal glands, bilateral for tumour (S1A12.1) Biochemical Investigations , CT , USG Post procedure evidence of USG,Biopsy

275 General surgery Splenorenal Anastomosis (S1A13.2) MRI , UGI Endoscopy , USG Post procedure evidence of USG, Endoscopy

276 General surgery Warren shunt (S1A13.3) MRI , UGI Endoscopy , USG Post procedure evidence of USG,Endoscopy

277 Genitourinary systemRenal transplantation surgery Inv - USG,RFT Post procedure evidence of

Clinical photograph (S9H1.2)

RFT, USG HOTA certificate for pre auth is

mandatory(for 1st case of transplant only in that

hospital)

OT Notes, Post procedure clinical photograph/

USG



Sr.



of Preauth


the time of Claim

278 Genitourinary system

A.V. Fistula (Pretransplant procedure only) Inv - Renal function tests,

Serum electrolytes Post procedure evidence of Clinical photograph

(S9H1.1)

RENAL FUNCTION TESTS, SERUM ELECTROLYTES Post procedure clinical photograph

279Genitourinary

systemTorsion Testis (S9H2.2) USG Post procedure clinical photograph

280Genitourinary

systemOrchidopexy Bilateral (S9H2.1) USG/ Clinical photograph Post procedure clinical photograph

281 Genitourinary systemLaparoscopic Pyelolithotomy

(S9H3.4)USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo

282 Genitourinary system Open Cystolithotomy (S9H3.3) USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo

283 Genitourinary systemOpen Nephrolithotomy

(S9H3.2)USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo

284 Genitourinary system Open Pyelolithotomy (S9H3.1) USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo

285Genitourinary

systemDj Stent (One Side) (S9H4.6) USG/KUB/IVP/ CT Abd X- RAY

286 Genitourinary system Nephrostomy (S9H4.5) USG/KUB/IVP/ CT AbdPost procedure clinical photograph post op x

ray kub mandatory for claim

287Genitourinary

systemURSL (S9H4.4) USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo

288Genitourinary

systemESWL (S9H4.3) USG/KUB/IVP/ CT Abd

during procedure photo . X

ray/USG

289Genitourinary

systemPCNL (S9H4.2) USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo

290Genitourinary

systemCystolithotripsy (S9H4.1) USG/KUB/IVP/ CT Abd USG / X ray

291 Genitourinary systemHypospadius Adult Double

Stage - TURBT (S9H5.8)Clinical photgraph Clinical Photgraph

292 Genitourinary system Urethroplasty For Stricture Urethra Double Stage Reconstruction Procedure (S9H5.4)clinical photo, RGU clinical photo

293 Genitourinary system Post-Transplant immunosuppressive Treatment from 7th to 12 th Month after transplantation (S9H6.1)RFT, USG BILLS COPY

294 Genitourinary systemAnderson Hynes Pyeloplasty

(S9H10.2)X ray, USG, IVP/ CT abd clinical photo

295 Genitourinary systemAnatrophic Pyelolithotomy For

Staghorn Calculus (S9H10.1)X ray, USG, IVP/ CT abd Post procedure clinical photograph, X- RAY/USG

296 Genitourinary systemEndoscope Removal Of Stone

In Bladder (S9H7.9)USG/KUB/IVP/ CT Abd

ENDOSCOPIC PHOTOGRAPH, USG/Xray

KUB

297Genitourinary

systemRenal Cyst Excision (S9H7.8) USG USG, histopath, Intra op Photo

298 Genitourinary system Nephrectomy Pyonephrosis/ XGP (S9H7.2)

IVP, USG/CT Abd

urine routine microscopy mandatory for pre

auth.

USG/ Biopsy

299 Genitourinary system Nephrostomy (S9H7.1) IVP, USG/CT AbdUSG/Xray post op photo of nephrostomy

required for claim

300 Genitourinary systemUreteric Reimplantation

(S9H8.6)IVP/ MCU, USG Intra op Photo, Post op Xray

301Genitourinary

system

Closure Of Urethral Fistula

(S9H8.3)

Retrograde Urethrogram, Clinical

photographPost procedure clinical photograph

302Genitourinary

system

Epispadiasis - Correction

(S9H8.2)CLINICAL PHOTOGRAPH Post procedure clinical photograph

303Genitourinary

systemVasico Vaginal Fistula (S9H8.1) IVP/MCU, Scopy clinical notes,

304 Genitourinary system Incontinence Urine (Male) (S9H9.7)

U.SCOPY, USG, UDS (optional),If USG is normal

then UDS ( Uro Diynamic study ) is to be done to

confirm the dignosis.

USG

305 Genitourinary system Incontinence Urine (Female) (S9H9.6)

USG, UDS optional

If USG is normal then UDS ( Uro Diynamic study )

is to be done to confirm the dignosis.

USG

306Genitourinary

systemTURP Cyst Lithotripsy (S9H9.1) USG with prostate size, PSA Biopsy, post op specimen photo

307Genitourinary

systemChordae correction (S9H2.3) Clinical photo Post procedure evidence of Clinical photograph

308 Genitourinary system Partial amputation of Penis(Non-Malignant) (S9H2.4) Clinical PhotographHistopath report,Post procedure clinical

photograph

309 Genitourinary system Total amputation of Penis(Non-Malignant) (S9H2.5) Clinical PhotographHistopath report,Post procedure clinical

photograph

310 Genitourinary system Optical Urethrotomy (S9H8.4) X-Ray, RGUPost procedure evidence of Intra operative

Endoscopic picture

311 Genitourinary system Urethroplasty for Stricture Urethra Single stage (S9H5.1) RGU Post procedure evidence of Clinical photograph

312 Genitourinary system Urethroplasty for Stricture Urethra Double Stage Stage -1 (S9H5.2) RGU Post procedure evidence of Clinical photograph

313 Genitourinary system Urethroplasty for Stricture Urethra Double Stage Stage -2 (S9H5.3)Clinical photo

RGU is mandatory for preauthPost procedure evidence of Clinical photograph

314 Genitourinary system Hypospadius Adult Single Stage (S9H5.5) Clinical Photograph Post procedure evidence of Clinical photograph

315 Genitourinary system Hypospadius Adult Double Stage - Stage-1 (S9H5.6) Clinical Photograph Post procedure evidence of Clinical photograph

316 Genitourinary system Hypospadius Adult Double Stage - Stage-2 (S9H5.7) Clinical Photograph Post procedure evidence of Clinical photograph



Sr.



of Preauth


the time of Claim

317 Genitourinary system Post-Transplant immunosuppressive Treatment from 1st to 6th Month after transplantation (S9H 1.3)RFT,USG BILLS COPY

318Genitourinary

systemSimple Nephrectomy (S9H7.3) USG, CT scan/IVP

Post procedure evidence of USG, histopath

report

319Genitourinary

system

Lap. Nephrectomy Simple

(S9H7.4)USG, CT scan Post procedure evidence of USG, Biopsy

320Genitourinary

system

Lap. Nephrectomy Radical


321Genitourinary

system

Lap. Nephrectomy Partial


322 Genitourinary systemBilateral Nephroureterectomy

(S9H7.7)USG, IVP Post procedure evidence of USG

323 Genitourinary systemPerineal Urethrostomy

(S9H8.5)X-Ray, RGU Post procedure evidence of clinical picture

324Genitourinary

system

Ileal Conduit formation

(S9H8.7)CT abd Post procedure evidence of Clinical photograph

325 Genitourinary system Ureterocele (S9H8.8) X Ray/ IVP/MCUPost procedure evidence of intra operative

Clinical photograph

326 Genitourinary system Transurethral resection of prostate (TURP) (S9H8.9)

USG with prostate size, PSA

USG WITH POST VOID VOLUME AT TIME OF

PREAUTH

Biopsy, post op specimen photo

327Genitourinary

systemOpen prostatectomy (S9H9.2) USG with prostate size, PSA Histopath, post op specimen photo

328Genitourinary

systemCaecocystoplasty (S9H9.3) USG, IVP/ MCU

Post procedure evidence of USG, clinical

photograph

329 Genitourinary system Total cystectomy (S9H9.4) USG, CT abdPost procedure evidence of USG ,Histopath

clinical photo

330 Genitourinary system Diverticulectomy (S9H9.5) USG, MCU, U.Scopy optionalPost procedure evidence of USG ,Histopath

clinical photo

331Gynaecology and

Obstetrics SurgeryAbruptioo placenta with coagulation defect – (S4C1.4)

USG / (APTT, S.FIBRINOGEN LEVEL, PT, PLATELET

COUNT, HAEMATOCRIT) Coagulation profile, LFT,

RFT

CLINICAL PHOTOGRAPH OF RETROPLACENTAL

CLOTS, USG

332Gynaecology and

Obstetrics Surgery

Eclampsia with complication requiring ventilatory support Inv –

(S4C1.3)

ABG, (S.FIBRINOGEN LEVEL, PT, PLATELET COUNT,

HAEMATOCRIT, APTT) / Sr. Uric acid , Sr. Creat,

Urine albumin , LFT/RFT

BIOCHEMICAL INVESTIGATIONS, Post procedure

clinical photograph

333Gynaecology and

Obstetrics SurgeryRupture Uterus (S4C1.2) USG USG, Clinical photograph/ HPE

334Gynaecology and

Obstetrics Surgery

Caesarean Hysterectomy with

Bladder Repair (S4C1.1)USG USG, PHOTOGRAPH

335Gynaecology and

Obstetrics Surgery

Vaginal Hysterectomy

(S4C2.17)USG HPE report

336Gynaecology and

Obstetrics Surgery

Laparoscopic adhesolysis

(S4C2.16)USG

HPE / VIDEO/ Sketch, USG Video is mandatory.

Sketch is not acceptable

337Gynaecology and

Obstetrics Surgery

Laparoscopic Sling operations

(S4C2.15)USG

VIDEO/ Sketch, USG/ HPE Video is mandatory.


338Gynaecology and

Obstetrics Surgery

Laparoscopic recanalisation

(S4C2.14)evidence of blockage, HSG

VIDEO/Sketch, /USG Video is mandatory.


339Gynaecology and

Obstetrics Surgery

Laparoscopic Myomectomy

(S4C2.13)USG

HPE, VIDEO/ Sketch, / USG Video is mandatory.


340Gynaecology and

Obstetrics SurgeryLaparoscopic ovarian drilling(S4C2.12) USG Usg , Video Is Mandatory.

341Gynaecology and

Obstetrics Surgery

Laparoscopic Ectopic Resection

(S4C2.11) USG Hpe, Usg,Video Is Mandatory.

342Gynaecology and

Obstetrics Surgery

Laparoscopic Cystectomy

(S4C2.10)USG HPE, Video is mandatory.

343Gynaecology and

Obstetrics SurgeryVault prolapse abdominal repair with mesh (S4C2.9) USG USG, Intra Op Photo showing Mesh

344Gynaecology and

Obstetrics SurgeryVault prolapse abdominal repair (S4C2.8) USG USG, Sketch

345Gynaecology and

Obstetrics SurgerySlings with mesh repair for prolapse (S4C2.7) USG USG, Sketch

346Gynaecology and

Obstetrics SurgeryMc Indo-s repair for Vaginal Atresia (S4C2.6) USG USG, Sketch

347Gynaecology and

Obstetrics SurgeryPelvic floor Reconstruction with mesh (S4C2.5) USG USG, Sketch

348Gynaecology and

Obstetrics SurgeryCystocele ,Rectocele & Perineorraphy (S4C2.4) USG USG, Sketch

349Gynaecology and

Obstetrics SurgeryVaginal Hysterectomy with Mesh repair (S4C2.3) USG HPE

350Gynaecology and

Obstetrics SurgeryVaginal Hysterectomy with pelvic floor repair (S4C2.2) USG HPE

351Gynaecology and

Obstetrics SurgeryLAVH (S4C2.1) USG HPE

352Infectious

DiseaseTetanus Severe (M5R1.1)

Clinical Photo of posture,

ABG

clinical photograph Post treatment e/o clinical

improvement,Swab for C/S

mandatory

353Infectious

DiseaseDiphtheria complicated (M5R1.2) ECG, Clinical photograph, Throat swab for C/S Lab investigations

354Infectious

DiseaseCryptococcal Meningitis (M5R1.3)

Investigation foe cryptococcal antigen/ CSF India

ink preparationLab investigations

355Interventional

RadiologyInferior Vena Cava Stenting Single Stent (M15W1.1) USG/ CT scan/ DSA IVC Gram

Post procedure

Angiographic Image



Sr.



of Preauth


the time of Claim

356Interventional

Radiology

Hepatic Vein Stenting In Budd - Chiari Syndrome Single Stent (M15W1.

2)CT/MRI Liver

Post procedure Angiographic Image Doppler is

mandatory for claims

357Interventional

Radiology

Acute Stroke Thrombolysis

With RTPA (M15W1.3)CT/ CT-perfusion/ MRI CT, Post Procedure DSA

358Interventional

Radiology

Renal Artery Embolization With Multiple Coils And Microcatheter

(M15W1.4)CT-Angiogram/ DSA Angiogram

Post procedure

Angiograpgic Image

359Interventional

Radiology

Cortical Venous Sinus

Thrombolysis (M15W1.5)CT/ MRI

Post procedure clinical Photograph,

Radiographic Image/CD

360Interventional

Radiology

Deep Venous Thrombolysis For

DVT With IVC Filter (M15W1.6)Color Doppler/ Clinical Photograph

Post procedure clinical photograph, Doppler/

Venographic DSA Image

361Interventional

Radiology

Subclavian, Iliac, Superficial Femoral Artery Stenting Each With One

Stent (M15W1.7)Angiogram / Doppler

Post procedure clinical photograph,

Radiographic Image/CD Stent sticker, Claims



video.

362Interventional

Radiology

Tibial Angioplasty In Critical

Limb Ischemia (M15W1.8)Angiogram / Doppler



363Interventional

Radiology

Mesenteric Artery Angioplasty

& Stenting In Acute & Chronic Mesenteric Ischemia - Single Stent

(M15W1.9)

Angiogram / CT angio


Radiographic Image/CD Stent sticker, Claims



video.

364Interventional

Radiology

Gastrointestinal Visceral Arterial Embolization In Upper And Lower

Gastrointestinal Bleeding With Microcatheter (M15W1. 10)USG Intra -op Video

365Interventional

Radiology

Bronchial Artery Embolization In Hemoptysis Using PVA And Micro

Catheter (M15w1.11)X-ray /CT chest Intra -op Video

366Interventional

Radiology

Radiofrequency Tumour

Ablation Therapy (M15W1.12)USG/CT/ MRI

Post procedure CT/MRI

scan

367Interventional

Radiology

Embolization Of Postoperative And Post Traumatic Bleeding (M15W1.

13)clinical photo req at the time of preauth



368Interventional

Radiology

Inferior Vena Cava Filter

Placement (M15W1.14)

COLOR DOPPLER/PERIPHERAL ANGIOGRAM IS




369Interventional

Radiology

Biliary Drainage Procedures - External Drainage And Stent Placement -

Single Metallic Stent (M15W1.15)CT/MRI/ USG/ERCP req at the time of preauth


Radiographic Image/CD STENT STICKER AT TIME

OF CLAIMS MANDATORY

370Interventional

RadiologyNephrostomy Tube And Nephroureteral Stent Placement (M15W1.16) USG/CT IS MANDATORY AT TIME OF PREAUTH.



371Interventional

Radiology

Uterine Artery Embolization In

Severe Menorrhagia

Secondary To PPH, Uterine

Fibroids And AVM (M15W1.17)

USG/CT IS MANDATORY AT TIME OF PREAUTH.Post procedure clinical photograph,


372Interventional

Radiology

Intra-Arterial Thrombolysis For

Acute Ischemic Limbs

(M15W1. 18)





373Interventional

Radiology

Permanent Tunnelled Catheter

Placement As Substitute For AV Fistula In Long Term Dialysis

(M15W1.19)





374Interventional

Radiology

Central Venous Stenting For Central Venous Occlusion (

Brachiocephalic, Subclavian Vein And Sup Vena Cava) Single Metallic

Stent (M15W1. 20)

COLOR DOPPLER IS MANDATORY AT TIME OF

PREAUTH.


Radiographic Image/CD STENT STICKER AT TIME

OF CLAIMS MANDATORY

375Interventional

Radiology

Endovascular Intervention For Salvaging Hemodialysis AV Fistula

(M15W1.21)

COLOR DOPPLER IS MANDATORY AT TIME OF

PREAUTH



376Interventional

Radiology

Balloon Retrograde Transvenous Obliteration Of Bleeding Gastric

Varices ( BRTO) (M15W1.22)clinical history



377Interventional

RadiologyPreoperative Portal Vein Embolization For Liver Tumors (M15W1. 23) USG/CT IS MANDATORY AT TIME OF PREAUTH.



378Interventional

Radiology

Chemo Embolization For Liver Tumors Using Drug And PVA Or DC Beads

(M15W1.24)USG/CT IS MANDATORY AT TIME OF PREAUTH.



379Interventional

Radiology

Percutaneous Vertebro Plasty/ Cementoplasty (For Each

Level) Post Procedure Evidence Of Clinical Photograph And

Radiographic Image (M15W1.25)

ANGIOGRAM IS MANDATORY AT TIME OF

PREAUTH



380Interventional

RadiologyTrans Jugular Intrahepatic Portosystemic Shunt (TIPSS) (M15W1. 26)

MRI/COLOR DOPPLER MANDATORY AT TIME OF

PREAUTH



381Interventional

Radiology

Embolization Of Pulmonary AV Malformation Post Procedure Evidence

Of Clinical Photograph And Radiographic Image (M15W1.27)CT/MRI MANDATORY AT TIME OF PREAUTH



382Interventional

RadiologyPreoperative Prophylactic Tumor Embolization (M15W1. 28) CT/MRI req at the time of preauth

Post Procedure Clinical Photograph,

Radiographic Image/Cd

383Interventional

Radiology

Embolization Of AV Malformation Of Brain Per Sitting With Onyx

(M15W1.29)CT/MRI MANDATORY AT TIME OF PREAUTH



384Interventional

RadiologyCarotid Stenting Single Stent With Protection Device (M15W1. 30) MRI/CT- Angiogram, Doppler

Post Porocedure DSA Stent sticker, Claims



video.

385Interventional

RadiologyIntracranial Arterial And Venous Stenting (M15W1.31) MRI/CT- Angiogram Post Procedure DSA

386Interventional

Radiology

Peripheral Stent Graft For Peripheral Aneurysms And Av Fistulae

(M15W1.32)CT or Doppler Post procedure angiography picture

387Interventional

RadiologyEmbolization Of Caratico- Cavernous Fistula (M15W1.33) CT/MRI MANDATORY AT TIME OF PREAUTH





Sr.



of Preauth


the time of Claim

388Interventional

Radiology

Embolization Of Av Malformation Of Peripheral Extremity, Craniofascial

And Visceral Per Sitting

(M15W1. 34)

CT scan/ MRI Post procedure Angiographic Image

389Medical

OncologyCyclophosphamide / Methotraxate / 5flurouracil (Cmf) (M1K1.5) Biopsy/Histopatholigy report Post treatment clinical notes & Chemo sheets

390Medical

OncologyPaclitaxel (M1K1.4)

Biopsy/Histopatholigy report, Planned

CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHPost treatment clinical notes & Chemo sheets

391Medical

Oncology

Adriamycin/Cyclophosphamide

(AC) (M1K1.1)



392Medical

Oncology

5- Flurouracil A-C (FAC) (M1K

1.2)



393Medical

OncologyAC (AC Then T) (M1K1.3)



394Medical

OncologyTamoxifen Tabs (M1K1.6)



395Medical

OncologyAromatase inhibitors (M1K1.7)



396Medical

Oncology

Bladder Cancer Weekly

Cisplastin (M1K2.1)USG, Biopsy/Histopatholigy report Post treatment clinical notes & Chemo sheets

397Medical

OncologyInduction Phase (M1K20.1)

CBC, BM Asp Biopsy, cytochemistry/ Surface

markersPost treatment clinical notes & Chemo sheets

398Medical

Oncology

Comsolidation Phase

(M1K20.2)BM Asp Biopsy Post treatment clinical notes & Chemo sheets

399Medical

OncologyMaintenance Phase (M1K20.3) CBC Post treatment clinical notes & Chemo sheets

400Medical

Oncology

Induction 1st And 2nd

Months(M1K21.1)

CBC, BM Asp Biopsy, cytochemistry/ Surface

markersPost treatment clinical notes & Chemo sheets

401Medical

Oncology

Induction 3rd, 4th, 5th

(M1K21.2)BM Asp Biopsy Post treatment clinical notes & Chemo sheets

402Medical

OncologyMaintenance Phase (M1K21.3) CBC Post treatment clinical notes & Chemo sheets

403Medical

Oncology

Palliative Chemotherapy

Unlisted Regimen (M1K22.1)Biopsy/Histopatholigy report, USG/CT Scan Post treatment clinical notes & Chemo sheets

404Medical

Oncology

Palliative And Supportive

Therapy (M1K23.1)Biopsy, USG/CT/ Blood test Post treatment clinical notes & Chemo sheets

405Medical

OncologyCisplastin/5-Fu (M1K24.1) Biopsy/Histopatholigy report Post treatment clinical notes & Chemo sheets

406Medical

OncologyXelox Along With Adjuvant Chemotherapy Of As- I(M1K25.1) CT Abdomen, Biopsy/Histopatholigy report USG/CT/Biopsy/Biochemical Investigations

407Medical

Oncology

2nd Line Iv Antibiotics And Other Supportive Therapy(Carbapenems,

Fourth Generation Cephalosporins, Piperacillin, Anti-Fungal . Azoles

Etc.,) (M1K27.2)

Clinical notes, CBC, Blood C/s / Urine C/S, Biopsy,

CXRUSG/CT/Biopsy/Biochemical Investigations

408Medical

Oncology

1st Line Iv Antibiotics And Other Supportive Therapy ( Third Generation

Cephalosporin, Aminoglycoside Etc.,) (M1K27.1)

Clinical notes, CBC, Blood C/s / Urine C/S, CXR/ CT

scan,USG/CT/Biopsy/Biochemical Investigations

409Medical

OncologyMethotraxate Vinblastin Adriamycin Cyclophosphamide (MVAC)

USG, Biopsy/Histopatholigy report Planned

CHEMOTHERAPY REGIMEN AT TIME OF PREAUTH


improvements & lab investigations

410Medical

OncologyCisplastin/Etoposide (IIIB) (M1K3.1)

X-Ray/CT Scan,Biopsy/FNAC Planned

CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts

411Medical

OncologyCisplastin- 5FU (M1K28. 1)

CT Scan/ USG, Biopsy Planned CHEMOTHERAPY

REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts

412Medical

Oncology5-FU Leucovorin (MCDONALD Regimen) (M1K5.1)

Endoscopy/CT Scan, Biopsy Planned


413Medical

OncologyMonthly 5-FU (M1K6.1)

Endoscopy/CT Scan, Biopsy, CEA Optional

Planned CHEMOTHERAPY REGIMEN AT TIME OF

PREAUTH

Clinical photograph, Chemo charts

414Medical

Oncology5- Flurouracil-Oxaliplastin Leucovorin (Folfox) (Stage III only) (M1K6.2)

Endoscopy/CT Scan, Biopsy Planned


415Medical

Oncology

Cisplastin/Adriamycin

(M1K12.1)

USG/CT Scan / Biopsy Planned CHEMOTHERAPY


416Medical

OncologyVincristin Adriamysin Dexmethasone (VAD) (M1K10.1)

Bone marrow, S. Immune electrophoresis, Bence

Jones Protiens (urine)


PREAUTH


417Medical

OncologyThalidomide + Dexamethasone oral (M1K10.2)


Jones Protiens (urine) Planned CHEMOTHERAPY

REGIMEN AT TIME OF PREAUTH




Sr.



of Preauth


the time of Claim

418Medical

Oncology

Melphalan Prednisone oral

(M1K10.3)




PREAUTH


419Medical

OncologyZoledronic acid along with Ajuvant Chemotherapy of AS-1 (M1K10.4)



Planned CHEMOTHERAPY

REGIMEN AT TIME OF PREAUTH


420Medical

OncologySIOP/NWTS Regimen (stages I III) -permonth (M1K11.1)

Biopsy / USG/CT


PREAUTH


421Medical

Oncology

Cervical Cancer Weekly

Cisplastin (M1K13.1)

Biospy, USG/CT


PREAUTH


422Medical

OncologyVariable regimen (M1K14.1)Hematology - Payable maximum upto

Tumour Biospy/Bone marrow aspi / USG/CT/PET-

CT & Planned CHEMOTHERAPY REGIMEN (any

change in regimen should be informed promptly)

Clinical Photograph, Chemo Charts

423Medical

Oncology

Variable regimen (M1K15.1)X-Ray/CT Scan - Payable maximum

upto/Per month

Biospy, CT scan/PET, Plan of

CHEMOTHERAPY REGIMEN(any change in regimen

should be informed promptly)


424Medical

Oncology

Carbo/Etoposide/Vincristin

(M1K16.1)

MRI/CT Orbit/USG orbit Planned CHEMOTHERAPY


425Medical

OncologyVariable regimen (M1K17.1)

Biopsy, CT/Skeletal study


PREAUTH(any change

in regimen should be informed

promptly)


426Medical

Oncology

Vincristin- Actinomycin- Cyclophosphamide (VACTC) based chemo per

month (M1K18.1)

Biospy, CT/USG/PET-CT Planned CHEMOTHERAPY


427Medical

Oncology

Variable regimen (M1K19.1)Hematology, Biopsy - Payable maximum

upto

Biopsy, Xray/CT/PET-CT Planned

CHEMOTHERAPY REGIMEN (any change in

regimen should be informed promptly)


428Medical

Oncology

Carboplastin / Paclitaxel

(M1K29.1)

Biopsy, USG/CT, Ca 125


PREAUTH


429Medical

OncologyBleomycin-Etoposide- Cisplastin (BEP) (M1K30.1)

Biopsy, USG/CT, S.A FP/ B HCG Planned


430Medical

Oncology

Weekly Methotrexate

(M1K31.1)

Biopsy , USG/CT, B HCG Planned CHEMOTHERAPY


431Medical

OncologyActinomycin (M1K31.2)



432Medical

Oncology

Etoposide -Methotrexate- Actinomycin/ Cyclophospamide Avincristine

(EMA-CO) (M1K32.1)



433Medical

OncologyBleomycin-Etoposide- Cisplastin (BEP) (M1K33.1)

Biopsy, USG/CT, S.A FP/ B HCG Planned


434Medical

Oncology

Hormonal therpay-per month

(M1K34.1)

Biospy, USG, PSA


PREAUTH


435Medical

OncologyCisplastin 5-FU (M1K4.1)

Biopsy, Endoscopy/CT scan Planned


436Medical

Oncology

Cisplastin / adriamycin

(M1K7.1)

Biospy, Xray/CT scan Planned CHEMOTHERAPY


437Medical

OncologyAdriamycin Bleomycin Vinblastin Dacarbazine (ABVD) (M1K8.1)

Biospy, CT scan/PET Planned CHEMOTHERAPY


438Medical

Oncology

Cyclophosphamide adriamycin

Vincristin prednisone (CHOP)

Biospy, CT scan/PET Planned CHEMOTHERAPY


439 Nephorology

Maintenance Haemodialysis

For CRF- 1 Day Stay Per Dialysis

(M8T2.6)

RFT , S. Protein, USG Abdomen, ( At the time of

first preauthorisation)


improvements & Sr. Creatinine photo of each

dialysis sessions mandatory for claim

440 NephorologyChronic Renal Failure 1 (CRF) -

5 Days Stay (M8T2.5)RFT, S. Protein, Sr. Electrolites, USG Abdomen



441 Nephorology Rapidly Progressive Renal Failure (RPRF)10 Days (M8T2.4)RFT, S. Protein, USG Abdomen, Sr.

Electrolytes, (ANA/DsDNA/ANCA/C3 /C4 optional)


improvements & lab investigations, Renal

Biopsy

442 NephorologyNephrotic Syndrome - 4 Days

Stay(M8T2.3)RFT, S. Protein, USG Abdomen, Sr. Electrolytes


improvements & lab investigations, Renal

Biopsy

443 NephorologyAcute Renal Failure-(ARF) -10

Days Stay In Micu (M8T2.2)RFT, S. Protein, USG Abdomen, Sr. Electrolytes



444 NeurologyImmunoglobulin Therapy -5

Days Stay(M9T3.11)

Investigation Indicative of Disease, CSF Analysis,

sr.pottassium

Post treatment evidence of

clinical improvements & lab investigations



Sr.



of Preauth


the time of Claim

445 Neurology Neuropathies (GBS) - 10 Days . Icu 20 Days - Ward Stay(M9T3.9) CSF Analysis, sr.pottassium


clinical improvements & lab

investigations, Nerve

Conduction Study, EMG

446 Neurology

Neuroinfections - Viral

Meningoencephalitis

(Including Herpes Encephalitis)

- Min 10 Days - Icu, 7 Days -

Ward Stay (M9T3.7)

CT/MRI Brain, CSF analysis, CSF Antibodies for HSVPost treatment evidence of clinical


447 Neurology

Neuroinfections - Pyogenic

Meningitis -Min 10 Days - Icu,

7 Days - Ward Stay (M9T3.6)

ADA, MRI BRAIN/CT BRAIN, CSF ANALYSIS, CELL

COUNT

Post treatment Evidence of clinical imrovement

,LAB INVESTIGATIONS

448 NeurologyIschemic Strokes-15 Days Stay

(M9T3.3)CT-Brain/ Carotid vertebral doppler


clinical improvements & lab investigations,

449 NeurologyHaemorrhagic Stroke/Strokes -

15 Days Stay(M9T3.2)CT-Brain/ MRI/MRV/MRA, ECG - not mandatory


clinical improvement & Lab investigations

450 NeurologyChronic inflammatory demyelinating polyneuropathy (CIDP) -10 Days

Stay(M9T3.1)

CSF ANALYSIS,SERUM PROTEIN

ELECTROPHORESIS, NERVE BIOPSY(optional), NCS,

EMG


,LAB INVESTIGATIONS

451 Neurology ADEM Or Relapse In Multiple Sclerosis 15 Days Stay(M9T3.12)MRI BRAIN/ SPINAL CORD (3 SITES) PLAIN/

CONTRAST, CSF ANALYSISCLINICAL IMPROVEMENT, LAB INVESTIGATIONS

452 NeurologyMyopathies - Acquired

(M9T3.4)

EMG, Serum alkaline phosphatase, Endocrine

evaluation, Muscle biopsy


,LAB INVESTIGATIONS

453 NeurologyNeuroinfections- Fungal

Meningitis (M9T3.5)CT Brain/MRI Brain, CSF analysis, cell count, ADA

Post treatment Evidence of

clinical imrovement ,LAB INVESTIGATIONS/

Blood Culture

454 Neurology Neuromuscular (Myasthaenia gravis) (M9T3.8)RNS/ CT chest/ Neostigmine test/

thyroid profile


clinical imrovement ,LAB INVESTIGATIONS

455 Neurology Optic Neuritis (M9T3.10) MRI Brain and optic nerves, VEPs, CSF analysis


clinical imrovement ,LAB

INVESTIGATIONS

456 NeurosurgeryEndoscopic Third

Ventriculostomy (S10I1.8)CT/MRI Clinical photo, Notes/CT/MRI

457 NeurosurgeryIntra-Cerebral Hematoma

Evacuation (S10I1.7)CT/MRI

Clinical photo,

Notes/CT/MRI post

op suture line photo mandatory for claim

458 Neurosurgery De-Compressive Craniotomy(Non Traumatic) (S10I1.6) CT/MRI

Clinical

photo,Notes/CT/Xray/MRI post op suture line

photo mandatory for claim

459 Neurosurgery Evacuation Of Brain Abscess - Burr Hole (S10I1.3) CT/MRI


photograph/CT/MRI

post op suture line photo mandatory for claim

460 NeurosurgeryCraniotomy And Evacuation Of

Hematoma Subdural (S10I1.1)CT/MRI


photograph/CT/MRI


461 Neurosurgery

Craniotomy And Evacuation Of

Hematoma Extradural

(S10I1.2)

CT/MRI


photograph/CT/MRI


462 Neurosurgery Excision of Lobe (Frontal, Temporal, Cerebellum etc.) (S10I1.4) CT/MRI Clinical photograph/ CT/MRI, HPE

463 Neurosurgery Parasagittal tumour (S10I2.1) CT/MRIClinical photograph/

CT/MRI, HPE

464 Neurosurgery Basal Brain Tumour (S10I2.2) CT/MRIClinical photograph/

CT/MRI, HPE

465 Neurosurgery Brain Stem Tumour (S10I2.3) CT/MRIClinical photograph/

CT/MRI, HPE

466 Neurosurgery Other Procedures (S10I3.1) CT/MRIClinical photograph/

CT/MRI, HPE

467 NeurosurgeryTemporal Lobectomy

(S10I10.1)MRI, VIDEO EEG, PSYCHOLOGIC ASSESSMENT

Clinical photograph/

CT/MRI, HPE post op

suture line photo mandatory for claim

468 Neurosurgery Lesionectomy type 1 (S10I10.2) MRI, VIDEO EEG, PSYCHOLOGIC ASSESSMENT Clinical photograph/ CT/MRI, HPE

469 Neurosurgery Lesionectomy type 2 (S10I10.3) MRI, VIDEO EEG, PSYCHOLOGIC ASSESSMENT Clinical photograph/ CT/MRI, HPE

470 NeurosurgeryTemporal lobectomy plus

Depth Electrodes (S10I10.4)MRI, VIDEO EEG, PSYCHOLOGIC ASSESSMENT Clinical photograph/ CT/MRI/Xray, HPE

471 NeurosurgeryMicro Vascular Decompression

(S10I11.2)CT/MRI Post procedure clinical photograph/CT/MRI

472 NeurosurgeryRadiofrequency Ablation

(S10I11.1)CT/MRI


photograph/CT/MRI

473 NeurosurgeryManagement of Aneurysm

Cost Of Each Coil (S10I12.2)CT/MRI/ DSA


photograph/CT/MRI/Angio

474 Neurosurgery Embolization (S10I12.1) CT/MRI/ DSAPost procedure clinical

photograph/CT/MRI/Angio

475 NeurosurgerySurgery on cord tumours

(S10I5.1)CT/MRI


CT/MRI, HPE

476 NeurosurgeryExternal Ventricular Drainage

(EVD) (S10I2.13)CT/ MRI Clinical photograph / Xray/ CT/ MRI

477 Neurosurgery Aneurysm Clipping (S10I2.12) CT/MRI /DSAClinical photograph/ X-

Ray/CT/MRI/angio



Sr.



of Preauth


the time of Claim

478 NeurosurgeryExcision Of Brain Abscess

(S10I2.11)CT/MRI


HPE/Pus c/s/CT/MRI

479 Neurosurgery Atrial shunt (S10I3.10) CT/MRIClinical photograph / Xray/

CT/ MRI

480 Neurosurgery Peritoneal shunt (S10I3.9) CT/MRIClinical photograph / Xray/

CT/ MRI

481 Neurosurgery

Ventriculolateral /

Ventriculoperitoneal Shunt

(S10I3.3)

CT/MRI Clinical photograph / Xray/ CT/ MRI

482 NeurosurgeryTwist Drill craniotomy

(S10I3.4)CT/ MRI Clinical photograph / Xray/ CT/ MRI

483 Neurosurgery Subdural Tapping (S10I3.5) CT/ MRIClinical photograph / Xray/

CT/ MRI

484 Neurosurgery Ventricular Tapping (S10I3.6) CT/ MRIClinical photograph / Xray/

CT/ MRI

485 Neurosurgery Abscess tapping (S10I3.7) CT/ MRIClinical photograph / Xray/

CT/ MRI/ Pus c/s

486 NeurosurgeryVascular malformations

(S10I3.8)MRI/CT/Angio Clinical photograph/MRI/CT/Angio

487 NeurosurgeryVentriculoatrial Shunt

(S10I2.10)CT/MRI


photograph/CT/Xray

488 Neurosurgery Meningocele Excision (S10I2.9) CT/MRIPost procedure clinical

photograph/CT/Xray

489 Neurosurgery Cranioplasty (S10I2.8) CT/MRIPost procedure clinical

photograph/CT/Xray

490 Neurosurgery C.S.F. Rhinorrhoea (S10I2.7) CT/MRIPost procedure clinical

photograph/CT/Xray

491 Neurosurgery Meningomylocele (S10I2.6) CT/MRIPost procedure clinical

photograph/CT/MRI

492 NeurosurgeryMeningoencephalocele

(S10I2.5)CT/MRI


photograph/CT/MRI

493 Neurosurgery C P Angle (S10I2.4) CT/MRIClinical photograph/

CT/MRI, HPE

494 NeurosurgeryExcision Of Brain Tumours

Subtentorial (S10I3.2)CT/MRI Clinical photograph/ CT/MRI, HPE

495 NeurosurgeryEndoscopy procedures

(S10I1.5)CT/MRI Endoscopy picture/CT/MRI

496 Neurosurgery C.V. Junction fusion (S10I6.5) MRI/ CT, X-RAY CERVICAL SPINEPost procedure clinical

photograph /X-RAY/CT/MRI

497 Neurosurgery Combined trans oral surgery and CV Junction fusion (S10I6.4) MRI/ CT, X-RAY CERVICAL SPINEPost procedure clinical photograph /X-

RAY/CT/MRI

498 Neurosurgery Trans oral surgery (S10I6.3) CT/MRIClinical photograph/

CT/MRI, HPE

499 NeurosurgeryTrans sphenoidal surgery

(S10I6.2)CT/MRI


CT/MRI, HPE

500 NeurosurgeryStereotactic procedures

(S10I6.1)CT/MRI Clinical photograph/ CT/MRI, HPE

501 NeurosurgerySpinal Fusion Procedure

(S10I5.12)MRI/ CT


photograph /Xray/CT/MRI, Bar code sticker if

allograft

502 Neurosurgery Discectomy (S10I5.11) MRI/ CTPost procedure clinical


503 Neurosurgery Laminectomy (S10I5.10) MRI/ CTPost procedure clinical


504 NeurosurgeryAnterolateral Decompression

(S10I5.9)MRI/ CT

Post procedure clinical photograph /X-

RAY/CT/MRI

505 NeurosurgeryAnterior Cervical Spine Surgery

With Fusion (S10I5.8)MRI/ CT, X-RAY CERVICAL SPINE


photograph /Xray/ CT/MRI Bar code sticker if

allograft

506 NeurosurgeryAnterior Cervical Spine Surgery

With Fusion (S10I5.8)MRI/ CT


RAY/CT/MRI

507 NeurosurgeryAnterior Cervical Discectomy

(S10I5.7)MRI/ CT


RAY/CT/MRI

508 NeurosurgeryExcision Of Cervical

Intervertebral Discs (S10I5.5)MRI/ CT


RAY/CT/MRI

509 NeurosurgerySpina Bifida Surgery Major

(S10I5.3)MRI/ CT



510 NeurosurgerySpina Bifida Surgery Minor

(S10I5.4)MRI/ CT



511 NeurosurgerySpinal Intramedullary Tumours

(S10I5.2)MRI/ CT Clinical photograph/Xray/ CT/MRI, HPE

512 NeurosurgerySpinal Fixation Rods And

Plates, Artificial Discs (S10I8.4)MRI/ CT X ray/CT/MRI

513 NeurosurgeryDiscectomy With Implants

(S10I8.2)MRI/ CT

X- RAY/CT/MRI, bar code

stickers

514 NeurosurgeryAnterior Discectomy & Bone

Grafting(S10I8.1)MRI/ CT X ray/CT/MRI

515 NeurosurgeryCorpectomy for Spinal Fixation

(S10I8.3)MRI/ CT X ray/CT/MRI

516 Neurosurgery Syringomyelia (S10I8.5) MRI/ CTPost procedure clinical

photograph/CT/MRI



Sr.



of Preauth


the time of Claim

517 NeurosurgeryRepair of Brachial plexus injury

(S10I9.1)NCV/EMG/CT/MRI Clinical photograph/EMG/NCV

518 NeurosurgeryCervical Sympathectomy

(S10I9.2)EMG,Nerve conduction CT/MRI Post procedure clinical photograph

519 NeurosurgeryLumbar sympathectomy

(S10I9.3)EMG,Nerve conduction /CT/MRI / Color doppler Clinical photograph/HPE

520 NeurosurgeryPeripheral Nerve Injury

Repair(S10I9.5)EMG, NERVE CONDUCTION Post procedure clinical photograph

521 Neurosurgery Proptosis (S10I9.6) MRI/ CTPost procedure clinical

photograph/CT/MRI

522 NeurosurgeryDecompression/ Excision Of

Optic Nerve Lesions (S10I9.4)MRI/ CT Post procedure clinical photograph/CT/MRI

523Opthalmology

SurgeryPediatric Cataract Surgery - Phacoemulsification . Iol (S3B10.2) B.SCAN, Post procedure clinical photograph

524Opthalmology

Surgery

Penetrating Keratoplasty

(S3B5.5)B.SCAN, Clincial Photograph Post procedure clinical photograph

525Opthalmology

SurgeryLamellar Keratoplasty (S3B5.2) B.SCAN Post procedure clinical photograph

526Opthalmology

Surgery

Removal Of Silicon Oil Or Gas

(S3B6.5)

B.SCAN, FUNDUS PHOTOGRAPH/

Sketch

FUNDUS PHOTOGRAPH/

Sketch

527Opthalmology

Surgery

Vitrectomy Plus Silicon Oil Or

Gas.(S3B6.6)B.SCAN, FUNDUS PHOTOGRAPH/ Sketch FUNDUS PHOTOGRAPH/ Sketch

528Opthalmology

SurgeryVitrectomy - Membrane Peeling Endolaser , Silicon Oil Or Gas(S3B6.4) B.SCAN, FUNDUS PHOTOGRAPH/ Sketch FUNDUS PHOTOGRAPH/ Sketch

529Opthalmology

Surgery

Vitrectomy + Membrane

Peeling+ Endolaser(S3B6.2)B.SCAN, FUNDUS PHOTOGRAPH/ Sketch FUNDUS PHOTOGRAPH/ Sketch

530Opthalmology

SurgeryVitrectomy(S3B6.1)

B.SCAN,

Fundus photograph is mandatory at time of

preauth


photograph Fundus photograph is mandatory

at time of claims

531Opthalmology

Surgery

Enucleation With Orbital

Implant(S3B7.4)CLINICAL PHOTOGRAPH, ORBIT Post procedure clinical photograph

532Opthalmology

Surgery

Lid Reconstruction Surgery

(S3B9.1)CLINICAL PHOTOGRAPH


photograph

533Opthalmology

SurgeryCorneal patch graft (S3B5.3) CLINICAL PHOTOGRAPH


photograph

534Opthalmology

SurgeryScleral patch graft (S3B5.4) CLINICAL PHOTOGRAPH


photograph

535Opthalmology

Surgery

Therapeutic Penetrating

Keratoplasty (S3B5.1)B.SCAN, Clincial Photograph Post procedure clinical photograph

536Opthalmology

SurgeryDouble Z plasty (S3B5.6) CLINICAL PHOTOGRAPH


photograph

537Opthalmology

Surgery

Amniotic membrane graft

(S3B5.7)CLINICAL PHOTOGRAPH


photograph

538Opthalmology

SurgeryScleral buckle for Retinal detachment (S3B11.1) B.SCAN, FUNDUS PHOTOGRAPH/ Sketch FUNDUS PHOTOGRAPH/ Sketch

539Opthalmology

SurgeryDermis fat graft (S3B7.2) CLINICAL PHOTOGRAPH


photograph

540Opthalmology

SurgeryOrbitotomy (S3B7.3) CT Scan


photograph

541Opthalmology

Surgery

Rectus muscle surgery single

(S3B8.1)CLINICAL PHOTOGRAPH Post procedure clinical photograph

542Opthalmology

Surgery

Rectus muscle surgery

Two/Three (S3B8.2)CLINICAL PHOTOGRAPH Post procedure clinical photograph

543Opthalmology

SurgeryOblique muscle (S3B8.3) CLINICAL PHOTOGRAPH


photograph

544Opthalmology

SurgeryPhotocoagulation for Retinopathy of prematurity (S3B10.1)

Fundus Fluorescence Angiography or Optical

Coherence Tomography , Fundus

Photograph/Sketch

Post procedure evidence of Clinical Photograph

showing procedure

545Opthalmology

Surgery

Glaucoma filtering surgery for paediatric Glaucoma

(S3B10.3)USG , OCT, Fundus Photograph/ Sketch

Post procedure evidence of

Clinical Photograph

546Opthalmology

Surgery

Socket reconstruction

(S3B7.1)CLINICAL PHOTOGRAPH Post procedure clinical photograph

547Opthalmology

Surgery

Monthly Intravitreal Anti - VEGF for macular degeneration - per

injection (maximum - 6) (S3B6.3)B.Scan , Fundus Photograph/ Sketch, OCT

Post procedure evidence of Fundus photo/

Sketch / optical coherence tomography.

548Opthalmology

SurgeryPhotocoagulation for diabetic retinopathy per sitting (S3B11.2) B.Scan , Fundus Photograph/Sketch


Fundus photograph/Sketch

549Orthopedic Surgery

and Procedures

Ilizarov Ring Fixator

Application.(S5D1.5)

X ray

mandatory requireed clinical photo of part for

pre auth

post procedure x ray


claim


and ProceduresReduction Of Compound Fractures & External Fixation(S5D1.4)

X ray

mandatory requireed clinical

photo of part for pre auth

post procedure x ray


claim


and Procedures

Open Reduction & Internal

Fixation Of Fingers & Toes

@Rs5000 Each Up To

Maximum Of Rs 15000(S5D1.3)

X- RAY post procedure x ray


and ProceduresExcision Or Other Operations For Scaphoid Fractures(S5D1.2) X- RAY post procedure x ray

553

Orthopedic

Surgery and

Procedures

Bone Grafting As Exclusive

Procedure(S5D1.1)X ray post procedure x ray



Sr.



of Preauth


the time of Claim


and Procedures

Amputations - Hind Quarter

And Hemipelvectomy (S5D2.3)x ray post procedure x ray / Clinical photgraph

555

Orthopedic

Surgery and

Procedures

Amputations - Forequarter

(S5D2.2)X- RAY post procedure x ray / Clinical photgraph

556

Orthopedic

Surgery and

Procedures

Open Reduction Of

Dislocations - Deep(S5D2.1)x ray post procedure x ray


and ProceduresSoft Tissue Reconstruction Procedures For Joints/ Osteotomy (S5D2.9)

clinical photo, X-ray mandatory requireed clinical

photo of part for pre auth

post procedure x ray /

Clinical photgraph mandatory requireed clinical

photo of part for pre auth and claim


and ProceduresAvascular Necrosis Of Femoral Head (Core Decompression)(S5D2.8) x ray, MRI post procedure x ray

559

Orthopedic

Surgery and

Procedures

Arthroscopy - Acl Repair

(S5D2.7)MRI/ Xray Arthoscopic video intra op, Xray


and Procedures

Arthroscopy. Operative

Meniscectomy (S5D2.6)MRI/ Xray Arthoscopic video intra op

561

Orthopedic

Surgery and

Procedures

Arthroscopy - Diagnostic

(S5D2.5)MRI/ Xray Arthoscopic video intra op

562

Orthopedic

Surgery and

Procedures

Arthrodesis Of - Major Joints

(S5D2.4)X- RAY X- RAY

563

Orthopedic

Surgery and

Procedures

Spinal Ostectomy And Internal

Fixations(S5D2.12)MRI/ Xray post procedure x ray


and Procedures

Anterolateral Clearance For

Tuberculosis(S5D2.10)MRI/ Xray BIOPSY, post procedure x ray


and Procedures

Operations For Brachial Plexus

& Cervical Rib (S5D2.15)Xray,NCS/EMG / MRI

Post procedure clinical photograph X-ray

mandatory during claims

566

Orthopedic

Surgery and

Procedures

Nerve Repair With Grafting

(S5D2.13)CLINICAL PHOTOGRAPH, NCS Post procedure clinical photograph


and ProceduresExcision Of Bone Tumours. Deep With Re-Construction With Conventional Prosthesis(S5D6.1)MRI/ Xray

Post procedure clinical photograph, post

procedure x ray, Biopsy

568

Orthopedic

Surgery and

Procedures

CTEV Neglected. JESS Fixator

(S5D1.6)Clinical Photograph


Clinical photograph, X-Ray

569

Orthopedic

Surgery and

Procedures

Neurolysis/Nerve Suture

(S5D2.14)Clinical Photograph


Clinical Photograph

570

Orthopedic

Surgery and

Procedures

Costo Transversectomy

(S5D2.11)MRI


Post op X-Ray

571 Pediatric Surgery Hirschsprung Disease Stage 2 (S8G1.8) CLINICAL PHOTOGRAPH/Imaging/ Biopsy BIOPSY, Post procedure scar photograph

572 Pediatric SurgeryAnorectal Malformations Stage

2(S8G1.6)

Clinical Photograph, Distal Cologram, USG

Abdomen, Xray Lumbosacral spine (inverted

position)

Post procedure Scar photograph operative/

procedure notes

573 Pediatric SurgeryAnorectal Malformations Stage

1(S8G1.5)

CLINICAL PHOTOGRAPH, Xray

Abdomen(Inverted position), Clinical NotesPost procedure Scar photograph

574 Pediatric SurgeryBiliary Atresis & Choledocal

Cyst(S8G1.4)CLINICAL PHOTOGRAPH, LFT, USG/ Imaging

Post procedure clinical photograph USG, LFT

GGT is mandatory at time of claims

575 Pediatric Surgery Intestinal Atresias & Obstructions(S8G1.3) X- RAY, Imaging


photograph USG/imaging is mandatory at

time of claims

576 Pediatric Surgery Diaphragmatic Hernia (S8G1.2) Chest X-ray AP/Lat, USG/CT scanChest xray AP/Lat Post

procedure clinical photograph

577 Pediatric Surgery Oesophageal Atresia (S8G1.1) X- RAY, TOF test req at time of

preauth. Post Procedure Clinical Photograph,

578 Pediatric SurgeryHypospadius Single Stage

(S8G2.6)CLINICAL PHOTOGRAPH


photograph

579 Pediatric Surgery Hypospadius Stage-1 (S8G2.15) CLINICAL PHOTOGRAPHPost procedure clinical

photograph

580 Pediatric SurgeryLymphangioma Excision

(S8G2.18)Neuro USG + CT Post Procedure Photo

581 Pediatric SurgeryHemangioma Excision

(S8G2.17)Neuro USG + CT Post Procedure Photo

582 Pediatric Surgery Hamartoma Excision (S8G2.16) CT / Clinical PhotographPost Procedure Photo,

Biopsy is mandatory at time of claims

583 Pediatric Surgery TM joint ankylosis (S8G2.14) CLINICAL PHOTOGRAPH / Xray Post Procedure Photo

584 Pediatric Surgery Microtia/ Anotia (S8G2.13) CLINICAL PHOTOGRAPH Post Procedure Photo

585 Pediatric Surgery Syndactyly of hand for each hand (S8G2.12) CLINICAL PHOTOGRAPH Post Procedure Photo

586 Pediatric SurgeryVelo-Pharyngial Incompetence

(S8G2.11)Endoscopy, Contrast Study Post Procedure Photo

587 Pediatric Surgery Cleft Palate (S8G2.10) CLINICAL PHOTOGRAPH Post Procedure Photo

588 Pediatric Surgery Cleft Lip (S8G2.9) CLINICAL PHOTOGRAPH Post Procedure Photo

589 Pediatric Surgery Pediatric Tumours (S8G2.8)Imaging / BIOPSY, tumour markers at time for

preauth

Post procedure clinical photograph Biopsy

should be mandatory for claims

590 Pediatric Surgery Hypospadius Stage- 2 (S8G2.7) CLINICAL PHOTOGRAPHPost procedure clinical

photograph



Sr.



of Preauth


the time of Claim

591 Pediatric SurgeryPosterior Urethral Valves

(S8G2.5)MCU / USG

clinical notes, clinical photo

with catheter

592 Pediatric Surgery Encephalocele (S8G3.4) MRI/ CT/ NEURO USGPost procedure clinical

photograph

593 Pediatric Surgery Neuroblastoma (S8G3.1) Imaging / biopsyUSG, BIOPSY,Post


594 Pediatric SurgeryCongenital Dermal Sinus

(S8G3.2)Neuro USG /CT Contrast study

Post Procedure Clinical

Photograph, Biopsy

595 Pediatric SurgeryCystic Lesions of the Neck

(S8G3.3)USG, MRI /CT, Clinical Photograph


Photograph, histopath

596 Pediatric SurgerySinuses & Fistula of the Neck

(S8G3.5)

USG/CT, contrast study, Clinical

Photograph



597 Pediatric SurgeryBronchoscopy Foreign Body

Removal(S8G4.1)Imaging/ ENDOSCOPIC VIDEO

Xray / clinical photograph,

/Scopy Photo/Video ensure bronchoscopy is

done only once

598 Pediatric Surgery Paediatric Esophageal Obstructions- Surgical Correction (S8G4.2) Contrast UGI Clinical Photograph

599 Pediatric SurgeryPaediatric Esophageal

Substitutions (S8G4.3)Contrast study Clinical Photograph

600 Pediatric SurgeryThoracoscopic Cysts Excision

(S8G4.4)USG / CT Post procedure clinical photograph, Biopsy

601 Pediatric SurgeryThoracoscopic Decortication

(S8G4.5)USG / CT Post procedure clinical photograph, Biopsy

602 Pediatric Surgery Thoracic Duplications (S8G4.6) Xray, CT Post procedure clinical photograph, Biopsy

603 Pediatric Surgery Thoracic Wall defects - correction (S8G4.7) Xray, CT Post procedure clinical photograph

604 Pediatric SurgeryGastric outlet Obstruction

(S8G5.1)Contrast USG, Xray Post procedure clinical photograph

605 Pediatric Surgery Laparoscopic pull through surgeries for HD (S8G5.2) USG/Biopsy, Clinical PhotographPost procedure clinical photograph, Biopsy,

Video

606 Pediatric SurgeryPaediatric Splenectomy (Non

Traumatic) (S8G5.3)USG, Heamogram, Post procedure clinical photograph, Biopsy, USG

607 Pediatric SurgerySurgeries on adrenal gland in

Children (S8G5.4)CT, Hormone Assays Post procedure clinical photograph, Biopsy, USG

608 Pediatric Surgery Hydatid cysts in Paediatric patient (S8G5.6) CT, USG Post procedure clinical photograph, Biopsy, USG

609 Pediatric Surgery Intestinal Polyposis Surgical correction (S8G5.7) USG/CT contrast studyPost Procedure Clinical


610 Pediatric SurgeryLaparoscopic

Choleycystectomy (S8G5.11)USG, Clinical photo


photograph, histopath, Video

611 Pediatric Surgery Laparoscopic pull through for Ano Rectal Anomalies (S8G5.12) CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph,VIDEO, USG

612 Pediatric SurgeryLaparoscopic Appendectomy

(S8G5.10)CLINICAL PHOTOGRAPH, USG


photograph,VIDEO

USG is mandatory during claims

613 Pediatric SurgeryPaediatric Acute Intestinal

Obstruction (S8G5.9)X-ray, CT/ USG


photograph,VIDEO

USG is mandatory during claims

614 Pediatric Surgery Intussusception(S8G5.8) CT/ USGPost procedure clinical

photograph, USG

615 Pediatric Surgery Torsion Testis(S8G6.5) clinical photo and colour doppler Clinical photo, Notes

616 Pediatric Surgery Hirschsprung Disease Stage 1 (S8G1.7) CLINICAL PHOTOGRAPH/Imaging/ Biopsy BIOPSY, Post procedure scar photograph

617 Pediatric SurgeryCongenital hydronephrosis

(S8G2.1)USG / Renogram


Clinical Photograph

618 Pediatric SurgeryUreteric reimplantations

(S8G2.2)Clinical Photograph/USG


Clinical Photograph

X-ray with Dj Stent for claim

619 Pediatric SurgeryExtrophy bladder Stage 1

(S8G2.3)

Clinical Photograph/USG, Xray

Pelvis


Clinical Photograph

620 Pediatric SurgeryExtrophy bladder Stage 2

(S8G2.4)

Clinical Photograph/USG, Xray

Pelvis


Clinical Photograph

621 Pediatric SurgeryGastro Esophageal Reflux

Correction (S8G5.5)Endoscopy, CT Scan / Contrast


Clinical Photograph

622 Pediatric Surgery Laparoscopic Varicocele ligation (S8G6.7)USG,/ Color Doppler Clinical

Photograph


Clinical

Photograph,USG,Video

623 Pediatric SurgeryLaparoscopic Orchidopexy

(S8G6.6)USG,Clinical Photograph

Clinical

Photograph,USG,Video

624 Pediatric Surgery Undescended Testis (S8G6.4) USG, Clinical PhotographPost procedure clinical

photograph

625 Pediatric Surgery Nephrectomy (S8G6.1) USG / CT Clnical PhotographPost procedure clinical

photograph, USG, Biopsy

626 Pediatric SurgeryEpispadiasis- Correction

(S8G6.2)CLINICAL PHOTOGRAPH Post Procedure Photo

627 Pediatric SurgeryScrotal transposition repair

(S8G6.3)CLINICAL PHOTOGRAPH Post Procedure Photo

628Pediatrics Medical

Management

Term Baby With Culture Positive Sepsis- Non Ventilated

Hyperbilirubinemia (M6S1.1)BLOOD CULTURE/ CBC , CRP, SERUM BILIRUBIN


AND LAB INVESTIGATIONS,

(Blood Culture/CRP/CBC)



Sr.



of Preauth


the time of Claim


Management

Term Baby, Fulminant Culture Positive Sepsis, Septic Shock, Ventilated,

Hyperbilirubinemia Renal Failure (M6S1.10)

BLOOD CULTURE / CBC, CRP, RFT, SERUM

BILIRUBIN, ABG

APGAR Score to be mandate at time of admission

Post procedure Evidence of


INVESTIGATIONS (Blood Culture/CRP/CBC/RFT)

USG ABDOMEN IS REQUIRED IN CLAIMS WHICH

WAS THERE PREVIOUSLY


Management

Term baby with persistent pulmonary hypertension Ventilation-HFO

Hyperbilirubinemia Clinical sepsis (M6S1.4)

Xray chest, ABG, Sr. Bilirubin,

2decho APGAR Score to be

mandate at time of admission

post treatment evidence of clinical

improvement and lab investigations, Xray chest,

ABG, Sr. Bilirubin


Management

33 To 34 Weeks Preterm Baby Severe Hyaline Membrane Disease

Clinical Sepsis Bubble CPAP Hyperbilirubinemia (M6S1.11)

ABG(optional), X- RAY CHEST, SERUM BILIRUBIN,

CRP, CBC 2d echo mandatory for pre auth



, Xray chest, / ABG


Management

33 To 34 Weeks Preterm Baby Severe Hyaline Membrane Disease With

Clinical Sepsis, Mechanical Ventilation Hyperbilirubinemia (M6S1.12)

ABG, X- RAY CHEST, SERUM BILIRUBIN, CBC / CRP

, Photo with ventilatory care APGAR Score to be



, Xray chest, / ABG


Management

35 To 36 Weeks Preterm Mild Hyaline Membrane Disease Culture

Positive Sepsis Nonventilated Hyperbilirubinemia ( )

BLOOD CULTURE/ CRP/ CBC, X- RAY CHEST,

SERUM BILIRUBIN APGAR Score to be mandate at

time of admission


,LAB INVESTIGATIONS (CBC, Sr bilirubin)


Management

33 To 34 Weeks Preterm Mild Hyaline Membrane Disease Culture

Positive Sepsis – Nonventilated Hyperbilirubinemia (M6S1.14)

CBC, CRP/ BLOOD CULTURE, X- RAY CHEST, SERUM

BILIRUBIN APGAR Score to be mandate at time

of admission


,LAB INVESTIGATIONS (CBC, Sr bilirubin)


Management

33 To 34 Weeks Preterm Severe Hyaline Membrane Disease Culture

Positive Sepsis Mechanical Ventilation/

Bubble Cpap

Hyperbilirubinemia ()

ABG, X- RAY CHEST, SERUM BILIRUBIN, CBC,

CRP/,BLOOD CULTURE APGAR Score to be



,LAB INVESTIGATIONS (CBC, Xray chest /ABG)


Management

30 to 32 weeks preterm Severe Hyaline membrane disease Clinical

sepsis Patent ductus arteriosus - Medical management Mechanical

ventilation Hyperbilirubinemia (M6S1.2)

2D ECHO , Blood culture / CRP, CBC ABG, Sr

Bilirubin, Xray chest

APGAR Score to be mandate at

time of admission




Management

30 To 32 Weeks Preterm Severe Hyaline Membrane Disease Clinical/

Culture Positive Sepsis Mechanical Ventilation Hyperbilirubinemia

(M6S1.16)


CRP/BLOOD CULTURE, Clinical photo wih

ventilatory care


,LAB INVESTIGATIONS (CBC,

Xray chest /ABG)


Management

<30 Weeks Preterm Severe Hyaline Membrane Disease Clinical/ Culture

Positive Sepsis Patent ductus arteriosus - Medical management

Mechanical Ventilation Hyperbilirubinemia (M6S1.3)

2D ECHO, Blood culture /CRP, CBC, ABG, Xray

chest, Sr Bilirubin





Management

<30 Weeks Preterm Severe Hyaline Membrane Disease Clinical/ Culture

Positive Sepsis Mechanical Ventilation Hyperbilirubinemia (M6S1.17)


CRP/BLOOD CULTURE APGAR Score to be



,LAB INVESTIGATIONS (CBC,

Xray chest /ABG)


Management

Term Baby With Severe Perinatal Asphyxia - Non Ventilated Clinical

Sepsis Hyperbilirubinemia (M6S1.5)

CBC, CRP/ BLOOD CULTURE, Sr Bilirubin APGAR

Score to be mandate at time of admission


,LAB INVESTIGATIONS, NEUROSONOGRAM/CT-

SCAN/ MRI


Management

Term Baby With Severe Perinatal Asphyxia - Ventilated Clinical Sepsis

Hyperbilirubinemia (M6S1.6)

CBC, CRP/ BLOOD CULTURE, , ABG

,X- RAY CHEST, Sr Bilirubin APGAR Score to be



,LAB INVESTIGATIONS, NEUROSONOGRAM/CT-

SCAN/ MRI


ManagementTerm Baby Severe Hyperbilirubinemia Clinical Sepsis (M6S1.7)

CBC / CRP, SERUM BILIRUBIN APGAR Score to be



clinical imrovement ,LAB INVESTIGATIONS,( CBC

Sr Bilirubin)

Blood culture is mandatory at time of claims


Management

Term Baby With Seizures

Ventilated (M6S1.8)

Blood sugar, Calcium, Electrolytes, CSF ANALYSIS,

ABG APGAR Score to be mandate at time of

admission


clinical imrovement AND

LAB INVESTIGATIONS NEUROSONOGRAM/CT-

SCAN/MRI)


Management

Necrotising enterocolitis, Clinical sepsis Non ventilated

Hyperbilirubinemia (M6S1.9)

CBC, CRP/Blood culture, Xray

Abdomen ultrasound optional

stool exam and usg mandatory for pre auth

post treatment evidence of clinical

improvement , Xray abdomen, CBC, CRP


Management

33 to 34 weeks preterm Severe Hyaline Membrane disease

Clinical/Culture positive sepsis Patent ductus arteriosus- Medical

management Mechanical ventilation Hyperbilirubinemia (M6S1.18)

2D ECHO , blood culture/ CRP,CBC, ABG, X-Ray

chest, Serum bilirubin APGAR Score to be





ManagementAcute Broncho/ Lobarpneumonia With Empyema/ Pleural Effusion (M6S10.1)X- RAY, CBC, Fluid Analysis X- RAY CHEST


ManagementAcute Broncho/ Lobarpneumonia With Pyo Pneumothorax 14 Days (M6S11.1)

BLOOD CULTURE/ CBC/CRP, X- RAY, PUS

CULTURE/ Gram stainX- RAY CHEST


Management

Congenital Heart Disease With

Congestive Cardiac Failure - 7

Days (M6S11.2)

2D ECHO, X- RAY chest, ECG CBC, sr electrolyte

requireed for pre auth

Post Procedure evidence of Post procedure

Evidence of clinical imrovement 2D ECHO, X-

RAY CHEST

649

Pediatrics

Medical

Management

Viral Myocarditis 7 Days Stay

(M6S11.4)2D ECHO, X- RAY, ECG 2D ECHO, X- RAY CHEST, ECG


Management

Steroid Resistant Nephrotic Syndrome Complicated Or Resistant - 2

Weeks Stay (M6S12.1)

URINE EXAM, RENAL BIOPSY SOS RFT'S

MANDATORY AT THE TIME OF PREAUTH.


AND LAB INVESTIGATIONS( Urine Albumin, HPE

if biopsy done)


ManagementUrinary Tract Infection With Complications Like Pyelonephritis And Renal Failure - 10 Days Stay (M6S12.2)

Urine R/M / URINE FOR CULTURE AND

SENSITIVITY/ USG, BUN, Sr. Creat


AND Urine culture/ UrineR/M / USG


Management

Acute Renal Failure 10 Days

Stay (M6S12.3)

RFT, ELECTROLYTES (optional)

ELECTROLYTES,C1,C3 MANDATORY AT PREAUTH,


AND LAB INVESTIGATIONS (RFT)



Sr.



of Preauth


the time of Claim

653

Pediatrics

Medical

Management

Acute Renal Failure With

Dialysis - 10 Days Stay

(M6S12.4)

RFT, Uric acid / SERUM ELECTROLYTES(optional)


clinical imrovement AND LAB INVESTIGATIONS

(RFT)


ManagementThalassemia Major Requiring Chelation Therapy - 7 Days Stay (M6S13.1)

HB ELECTROPHORESIS/ HPLC, SERUM FERRITIN(6

monthly)reqCase Sheet With Records Of Chelation Therapy


Management

Haemophilia Including - 7 Days

Stay (M6S13.2)

VON WILL BRANDS / FACTOR VIII/ IX ASSAY

Coagulation Parameters


clinical imrovement , case sheet with records of

factor given


Management

Anaemia Of Unknown Cause 5

Days Stay (M6S13.3)

BONE MARROW EAMINATION SOS, HAEMOGRAM

/ HB ELECTROPHORESIS


AND LAB INVESTIGATIONS ( CBC)


ManagementPyogenic Meningitis with 10 days stay (M6S14.1) X- RAY CHEST, CSF ANALYSIS

Post Procedure Evidence Of Clinical Imrovement

And Csf Analysis

658

Pediatrics

Medical

Management

Neuro Tuberculosis- 12 Days

Stay (M6S14.2)CT- SCAN BRAIN, CSF ANALYSIS, X- RAY CHEST


clinical imrovement AND LAB INVESTIGATIONS

659

Pediatrics

Medical

Management

Neuro Tuberculosis With

Ventilation- 12 Days Stay

(M6S14.3)

CT- SCAN BRAIN, CSF ANALYSIS, X- RAY CHEST,

ABG



INVESTIGATIONS


ManagementSuspected Dengue Shock Syndrome With Thrombocytopenia (M6S14.4)

CBC (PLATELET COUNT) / Dengue

SEROLOGY

EVIDENCE OF PLATELET TRANSFUSION If given,

CBC

661

Pediatrics

Medical

Management

Cerebral Malaria (Falciparum)

7 Days Stay (M6S14.5)

Test for P. Falciparum PARASITE , CSF ANALYSIS,

Blood sugar



INVESTIGATIONS


ManagementConvulsive Disorders/Status Epilepticus (Fits) - 7 Days Stay (M6S15.1) BLOOD SUGAR, ELECTROLYTES


clinical imrovement ,LAB INVESTIGATIONS EEG /

CT- brain,

663

Pediatrics

Medical

Management

Stroke Syndrome 14 days stay

(M6S15.2)CT

post treatment evidence of clinical and lab

investigation

664

Pediatrics

Medical

Management

Encephalitis / Encephalopathy

- 10 Days Stay (M6S15. 3)CSF Analysis, CT-brain/ MRI


clinical imrovement ,LAB INVESTIGATIONS


Management

Guillian-Barre Syndrome- 15

Days Stay (M6S15.4)

ENMG NERVE CONDUCTION STUDIES, CSF

ANALYSIS optional, S. electrolytes mandatory

during preauth.If NCS report is not positive then

in that case CSF analysis should show increase in

protein to confirm dignosis

Post procedure Evidence of clinical imrovemen,

LAB INVESTIGATIONS

666

Pediatrics

Medical

Management

Severe Bronchiolitis (Non

Ventilated) (M6S2.1)X- RAY CHEST, CLINICAL PHOTOGRAPH X-ray

667

Pediatrics

Medical

Management

Severe Bronchiolitis

(Ventilated) (M6S2.2)X- RAY CHES, ABG, CLINICAL PHOTOGRAPH X-ray, ABG


Management

Severe Bronchopneumonia

(Non Ventilated) (M6S2.3)

X-Ray Chest ABG MANDATORY

AT TIME OF PREAUTHX-ray


Management

Severe Bronchopneumonia

(Ventilated) (M6S2.4)

Clinical photo with ventilatory support SERIAL

ABG, X-RAY CHESTX-ray, ABG

670

Pediatrics

Medical

Management

Acute Severe Asthma



ABG, X-RAY CHESTX-ray, ABG

671

Pediatrics

Medical

Management

Severe Aspiration Pneumonia

(Non Ventilated) (M6S2.6)X-RAY CHEST



Xray, LAB INVESTIGATIONS


Management

Severe Aspiration Pneumonia



ABG, X-RAY CHEST


AND Xray chest, ABG

673

Pediatrics

Medical

Management

ARDS With Multi- Organ

Failure (M6S2.8)

ABG, X- RAY CHEST, RFT ,LFT, CLINICAL

PHOTOGRAPH

ABG, LAB INVESTIGATIONS

(LFT, RFT), Xray chest

BLOOD CULTURE AT CLAIM


Management

ARDS Plus Dic (Blood & Blood

Products) (M6S2.9)

ABG optional, X- RAY CHEST, COAGULATION

PROFILE

Xray chest, LAB

INVESTIGATIONS( Coagulation profile optional)

BLOOD CULTURE AT CLAIM


ManagementSevere Myocarditis (M6S3.1) ECG, 2 D Echo, Xray chest


Imrovement And X-Ray


ManagementCongenital Heart Disease With Infection (Non Ventilated) (M6S3.2) CBC / CRP , 2 D ECHO, X-RAY CHEST


AND X- ray


Management

Congenital Heart Disease With Infection And Cardiogenic Shock


X- RAY CHEST, SERIAL ABG,

2DECHO, clinical photo with ventilatory support


Photo AND ABG, X-ray


ManagementAcquired heart disease with congestive cardiac failure (M6S11.3) X-Ray, 2D Echo, ECG


X-Ray Chest, 2D Echo, ECG

679

Pediatrics

Medical

Management

Cardiogenic Shock (M6S3.4) X-RAY CHEST, ECHO /CVP Monitoring


clinical imrovement Photo

AND X-ray

680

Pediatrics

Medical

Management

Infective Endocarditis (M6S3.5) CBC, CRP/ BLOOD CULTURES X- RAY CHEST, ECHO


clinical imrovement Photo

AND Blood culture


Management

Meningo-Encephalitis (Non

Ventilated) (M6S4.1)CSF ANALYSIS, CT- SCAN


clinical imrovement AND LAB INVESTIGATIONS (

CSF analysis)



Sr.



of Preauth


the time of Claim


Management

Meningo- Encephalitis


SERIAL ABG, CT- SCAN, CSF ANALYSIS, Clinical

photo with ventilatory support



LAB INVESTIGATIONS ( CSF

analysis)


ManagementStatus Epilepticus (M6S4.3) Clinical Notes, EEG optional


clinical imrovement WITH LAB

INVESTIGATIONS, EEG/ CT scan


ManagementFebrile Seizures (Atypical- Mechanical Ventilated) (M6S4.4) CSF ANALYSIS, SERIAL ABG,


WITH LAB INVESTIGATIONS, EEG/ CT scan

685

Pediatrics

Medical

Management

Intra Cranial Bleed (M6S4.5) CT- SCAN/ MRIPost procedure Evidence of

clinical imrovement WITH LAB INVESTIGATIONS


Management

Acute Pancreatitis - 10 Days

Picu Stay (M6S5.2)

SERUM AMYLASE, LIPASE, USG/CT SCAN

ABDOMEN


clinical imrovement WITH LAB

INVESTIGATIONS( Sr. Amylase, Sr lipase)


Management

Acute Hepatitis With Hepatic Encephalopathy – 10 Days Picu Stay

(M6S5.3)

LFT, / S. AMMONIA, HEPATIC VIRAL STUDIES

(HEPATITIS B, HEPATITIS

C), (HEPATITIS A optional) SERIAL ABG, BLOOD

SUGAR LEVELS, USG MANDATORY AT PREAUTH


WITH LAB INVESTIGATIONS ( LFT, Sr. Ammonia)


ManagementAcute Renal Failure With Dialysis - 10 Days Picu Stay (M6S6.1)

RFT, SERUM ELECTROLYTES, XRAY

CHEST, USG MANDATORY

Post Procedure Evidence Of Clinical Imrovement

And Lab Investigations (Rft)


Management

Septic Shock- 10 Days Picu Stay

(M6S8.1)

CBC/CRP / BLOOD CULTURE, X- RAY CHEST

SERIAL ABG, BLOOD SUGAR LEVELS MANDATORY

AT PREAUTH


WITH LAB INVESTIGATIONS(CBC, CRP)

690

Pediatrics

Medical

Management

Acute Gastro intestinal bleed

(M6S5.1)Upper GI Endoscopy

post treatment evidence for

Clinical Improvement with lab investigations,


Management

Diabetic Ketoacidosis

(M6S7.1)

ABG optional, Blood sugar, Urine

Ketone

post treatment evidence for

Clinical Improvement with biochemical

parameters, Blood Sugar,


ManagementSnake bite requiring ventilatory assistance (M6S9.1) Serial ABG, coagulation profile(optional)

PICU stay with post

treatment evidence for

Clinical Improvement with biochemical

parameters, ABG


Management

Scorpion sting with myocarditis and cardiogenic shock requiring

ventilatory Assistance (M6S9.2)

Serial ABG, Echo, ECG, CVP

monitoring

post treatment evidence for Clinical

Improvement with lab investigations


ManagementPoison ingestion/ aspiration requiring ventilatory assistance (M6S9.3)

Serial ABG, CVP

monitoring(optional)

post treatment evidence for Clinical

Improvement with biochemical parameters,

MLC

695 Plastic Surgery Cleft lip (S12M1.1) Clinical photo of affected partClinical photo of affected

part

696 Plastic Surgery Cleft Palate (S12M1.2) Clinical photo of affected partClinical photo of affected

part

697 Plastic SurgeryVelo-Pharyngial Incompetence

(S12M1.3)Naso Endoscopy / Fluroscopy Clinical photo of affected part

698 Plastic Surgery Syndactyly of Hand for each hand (S12M1.4) Clinical photo of affected part Clinical photo of affected part

699 Plastic Surgery Microtia/Anotia (S12M1.5) Clinical photo of affected partClinical photo of affected

part

700 Plastic Surgery TM joint ankylosis (S12M1.6) Clinical Phoptograph, X-Ray / OPGClinical Phoptograph / OPG/

Xray

701 Plastic SurgeryHemifacial Microsomia

(S12M1.7)CT/ Xray / OPG Clinical photo of affected part

702 Plastic SurgeryLeprosy reconstructive surgery

(S12M1.8)Clinical photograph Clinical photo of affected part

703 Plastic Surgery Nerve and tendon repair + Vascular repair (S12M1.9) Clinical photograph Clinical photo of affected part

704 Plastic Surgery Ptosis (S12M1.10) Clinical photo of affected partClinical photo of affected

part

705 Plastic Surgery Tumour of mandible and maxilla (S12M1.11) CT/MRI/Xray/HPE clinical photograph Clinical Phoptograph/ Xray, Biopsy report

706 Plastic Surgery Vaginal atresia (S12M1.12) Clinical notes with sketch Sketch/ Clinical photograph

707 Plastic SurgeryVascular malformations

(S12M1.13)Angiogram / MR angio/ CT angio Clinical photo of affected part

708 Plastic SurgeryCorrective Surgery for Congenital deformity of hand (per hand)

(S12M1.14)X-Ray, clinical photograph Clinical Phoptograph/ Xray

709 Plastic SurgeryCorrective Surgery for

Craniosynostosis (S12M1.15)CT, Clinical photograph Clinical photo of affected part

710 Plastic Surgery Cup and Bat ears (S12M1.16) Clinical photo of affected partClinical photo of affected

part

711 Plastic Surgery Flap cover for Electrical burns with vitals exposed (S12M1.17) Clinical photo of affected part Clinical photo of affected part

712 Plastic Surgery Reduction surgery for Filarial lymphedema (S12M1.18) Clinical photo of affected part Clinical photo of affected part

713 Plastic Surgery Hemifacial atrophy (S12M1.19) Clinical photographClinical photo of affected

part

714 Poly Trauma Soft Tissue Injury(S14O1.3) clinical photo clinical photo

715 Poly Trauma Amputation Surgery (S14O1.2) X- RAYPost procedure clinical

photograph

716 Poly Trauma Open Reduction And Internal Fixation Of Long Bone Fractures (S14O1.1) X rayX ray,

OT Notes

717 Poly Trauma Grade I& II (S14O10.1) CLINICAL PHOTOGRAPH, X- RAYPost procedure clinical

photograph OT Notes

718 Poly Trauma Surgical Correction Of Pelvic Bone Fractures. (S14O11.6) X- RAY X- RAY OT Notes



Sr.



of Preauth


the time of Claim

719 Poly Trauma Facial Bone Fractures (Faciomaxillary Injuries) (S14O11.5) CLINICAL PHOTOGRAPH, X- RAYPost procedure clinical photograph, X- RAY

OT Notes

720 Poly TraumaSmall Bone Fractures K-Wiring (To Be Covered With Other Injuries Only

And Not As Exclusive Procedure) (S14O11.4)X- RAY

X- RAY

OT Notes

721 Poly TraumaSurgery For Patella Fracture (To Be Covered With Other Injuries Only

And Not As Exclusive Procedure)(S14O11.3)X- RAY

X ray

OT Notes

722 Poly Trauma Flap Cover Surgery For Wound In Compound Fracture (S14O11.2) CLINICAL PHOTOGRAPH, X- RAYPost procedure clinical photograph, Xray

OT Notes

723 Poly Trauma Grade -III (S14O11.1) CLINICAL PHOTOGRAPHPost procedure clinical

photograph

724 Poly TraumaStay In Neuro

[email protected]/Day (S14O2.2)X- RAY/ CT/ MRI Post procedure clinical photograph

725 Poly TraumaStay In General Ward

@Rs.500/ Day (S14O2.1)X- RAY/ CT Post procedure clinical photograph

726 Poly Trauma Surgical Treatment (Up To) (S14O3.1)

X- RAY/CT/MRI, It includes following

neurosurgical procedures carried out on

polytrauma patient For example -Craniotomy for

extradural and subdural hematoma,

decompressiion craniotomy, elevation of all

depressed fractures and surgeries for CSF leak,

emergency surgery for high ICP and cranioplasty.

Post procedure clinical photograph, Lab

Investigation

727 Poly TraumaStay In Respiratory Icu

[email protected]/Day (S14O4.2)X- RAY/CT, Clinical photograph Post procedure clinical photograph

728 Poly Trauma

Chest Injuries Conservative

Stay In General Ward

@Rs.500/Day (S14O4.1)

X- RAY/CT Post procedure clinical photograph

729 Poly Trauma Polytrauma Chest Surgical Treatment (S14O5.1) X-RAY/USG/CT X-Ray/Usg/Ct

730 Poly TraumaStay In Surgical

[email protected]/Day (S14O6.2)X-RAY/USG/CT USG

731 Poly TraumaAbdominal Injuries Conservative Stay In General Ward @Rs.500/Day

(S14O6.1)X-RAY/USG/CT USG

732 Poly TraumaAbdominal Injuries Surgical

Treatment(S14O7.1)

X-RAY/USG/CT .It includes abdominal trauma

management of polytrauma patient which include

Spleenectomy, Mesentric artery tears, Bowel

tears, Liver injuries, Intraabdominal hemorrhage

USG, Post procedure clinical photograph

733 Poly Trauma Thoracostomy(S14O8.2) CLINICAL PHOTOGRAPHPost procedure clinical

photograph

734 Poly Trauma Tracheostomy(S14O8.1) CLINICAL PHOTOGRAPHPost procedure clinical

photograph

735 ProsthesesLower Limb Symes Prostheses

HDP/PP (S15P2.1)CLINICAL PHOTOGRAPH

CLINICAL PHOTOGRAPH clinical photograph

with prosthesis mandatory for claim


Fibre (S15P2.2)CLINICAL PHOTOGRAPH

CLINICAL PHOTOGRAPH

clinical photograph with prosthesis mandatory

for claim


Modular (S15P2.3)CLINICAL PHOTOGRAPH

CLINICAL PHOTOGRAPH

clinical photograph with

prosthesis mandatory for claim

738 Prostheses Below Knee(BK/PTB) Prostheses HDP/PP (S15P3.1) CLINICAL PHOTOGRAPH

CLINICAL PHOTOGRAPH


for claim

739 Prostheses Below Knee(BK/PTB) Prostheses Fibre (S15P3.2) CLINICAL PHOTOGRAPH

CLINICAL PHOTOGRAPH


for claim

740 Prostheses Below Knee(BK/PTB) Prostheses Modular (S15P3.3) CLINICAL PHOTOGRAPH

CLINICAL PHOTOGRAPH


for claim

741 ProsthesesThrough Knee Prostheses


CLINICAL PHOTOGRAPH


for claim

742 ProsthesesThrough Knee Prostheses Fibre

(S15P4.2)CLINICAL PHOTOGRAPH



743 ProsthesesThrough Knee Prostheses


CLINICAL PHOTOGRAPH


for claim

744 ProsthesesAbove Knee(AK) Prostheses


CLINICAL PHOTOGRAPH


for claim









747 ProsthesesHip Disarticulation Prosthesis












750 ProsthesesHip Disarticulation Partial Foot

Prosthesis (S15P6.4)CLINICAL PHOTOGRAPH





Sr.



of Preauth


the time of Claim

751 ProsthesesBelow Elbow Prosthesis




752 ProsthesesBelow Elbow Prosthesis Fibre




753 ProsthesesBelow Elbow Prosthesis




754 ProsthesesAbove Elbow Prosthesis




755 ProsthesesAbove Elbow Prosthesis Fibre




756 ProsthesesAbove Elbow Prosthesis




757 ProsthesesWhole Upper Limb Prosthesis




758 ProsthesesWhole Upper Limb Prosthesis




759 ProsthesesWhole Upper Limb Modular




760 Pulmonology Bronchiectasis requiring hospitalisation (M10T4.8) HR CT - Chest , sputum gram stain

post treatment evidence of Clinical and Lab

Investigations, Sputum culture /drug

susceptibility

761 PulmonologyLung Abscess, non resolving

(M10T4. 1)CT Scan Chest,


Investigations, Pus C/S

762 PulmonologyPneumothorax

(Large/Recurrent) (M10T4.2)Chest HRCT


Investigations Xray

763 PulmonologyInterstitial Lung diseases

(M10T4. 3)HRCT Chest


Investigations, Spirometry

764 Pulmonology Pneumoconiosis (M10T4. 4) HRCT Chestpost treatment evidence of Clinical and Lab

Investigations

765 PulmonologyAcute Respiratory Failure

(without ventilator) (M10T4.5)

Serum Electrolytes, ABG, ECG, Sputum / Bronchial

Washing / ET Suctions for Analysis x ray

mandatory for pre auth.


Investigations

766 Pulmonology Acute Respiratory Failure (with ventilator) (M10T4.6)

Serum Electrolytes, ABG, ECG, Sputum / Bronchial

Washing / ET Suctions for Analysis x ray

mandatory for pre auth.


Investigations

767 Radiation Oncology Cobalt 60 External Beam Radiotherapy (M2L1.1) Radical TreatmentBiopsy/Histopathology report, USG/CT/X-RAY/or

any other relevent Imaging

RT Treatment Charts, For planning phase-

marker cell or simulation cell report

768 Radiation Oncology Cobalt 60 External Beam Radiotherapy (M2L1.2) Palliative TreatmentBiopsy/Histopathology report, USG/CT/X-RAY/or




769 Radiation Oncology Cobalt 60 External Beam Radiotherapy (M2L1.3) Adjuvant TreatmentBiopsy/Histopathology report,USG/CT/X-RAY/or




770 Radiation OncologyExternal Beam Radiotherapy (On Linear Acclerator) (M2L2.1) Radical

Conventional Treatment with Photons

Biopsy/Histopathology report, USG/CT/X-RAY/or




771 Radiation OncologyExternal Beam Radiotherapy (On Linear Acclerator) (M2L2.2) Palliative

Treatment With Photons

Histopathology report, USG/CT/X-RAY/or any

other relevent Imaging



772 Radiation OncologyExternal Beam Radiotherapy (On Linear Acclerator) (M2L2.3) Adjuvant

Treatment With Photons/Electrons





773 Radiation OncologyBrachytherapy Intracavity (M2L3.1) A) Intracavitary I. LDR Per

Application



Brachytherapy Details, For planning phase-


774 Radiation OncologyBrachytherapy Intracavity (M2L3.2) A) Intracavitary II. HDR Per

Application



Brachytherapy Details, For planning phase-


775 Radiation OncologyBrachytherapy Interstitial (M2L4.1) B) Interstitial I. LDR Per Application/

Surface mould (LDR/HDR)



Brachytherapy Details with Simulation X-ray or

CT Scan or MRI or USG, For planning phase-


776 Radiation Oncology

Brachytherapy Interstitial (M2L4.2) B) Interstitial II. HDR One

Application and Single/Multiple Dose Fractions (For Current Rate) &

Interstitial Implant with Complete Treatment



Brachytherapy Details and Implant simulation X-

ray or CT scan or MRI or USG, For planning

phase- marker cell or simulation cell report

777 Radiation OncologySpecialized Radiation Therapy - Imrt (Intensity Modulated

Radiotherapy)

Biopsy/Histopathology report,USG/CT/X-RAY/or


RT TREATMENT CHARTS, For planning phase- CT

planning image, Claim will be paid as per

adjudication guidelines

778 Radiation OncologySpecialized Radiation Therapy - 3dcrt(3-D Conformational

Radiotherapy) (M2L6.1) 3DCRT-Up To 30 Fractions In 6 Weeks

Biopsy/Histopathology report, USG/CT/X-Ray/or





779 Radiation OncologySpecialized Radiation Therapy - SRS/SRT (M2L7.1) SRS (1 or 2

fractions)/SRT- more than 25 fractions






780 Radiation OncologySpecialized Radiation Therapy Volumetric IMRT (Rapid Arc/VMAT/or

Any other commercial Volumetric IMRT) Therapy (M2L8.1)






781 Radiation OncologySpecialized Radiation Therapy - IMRT with IGRT (M2L9.1) IMRT+IGRT-

Up To 40 Fractions In 8 Weeks






782 RheumatologySLE (Systemic Lupus Erythematosis) 10 Days

Stay(M12T6.6)

24 Hour urine protein, ACL Antibodies / ANA/ Anti

DSDNA/ C3 C4


improvement, Lab Investigation

783 Rheumatology SLE with Sepsis 4 weeks stay (M12T6. 1)ANA/Anti DSDNA (new or old

report), Blood Culture or source of infection



784 Rheumatology Scleroderma 7 Days stay (M12T6. 2) Anti SCL 70, ANA (old or new) / skin biopsy/ PFTPost treatment evidence of Clinical


785 Rheumatology MCTD Mixed connective tissue disorder 7 days stay (M12T6. 3)ANA, Anti U1 RNP ab, (old or new)

/Renal biopsy/ CPK





Sr.



of Preauth


the time of Claim

786 Rheumatology Primary Sjogren's Syndrome 7 days stay (M12T6.4)ANA, Anti-Ro & Anti- La antibody

(old or new)


clinical improvement, Lab Investigation

787 RheumatologyVasculitis 10 days stay

(M12T6. 5)ANCA<PC, ANA / Renal biopsy/ Skin biopsy/ NCS



788Surgical

Gastroenterology

Diaphragmatic Hernia (Gortex

Mesh Repair) (S6E1.3)

X- ray,

USG and Barium study mandatory during preauthpostop plain x ray & intaoperative photo

789Surgical

Gastroenterology

Surgery For Obscure GI Bleed

(S6E1.2)ENDOSCOPY ENDOSCOPIC PHOTOGRAPH/ Sketch

790Surgical

Gastroenterology

Surgery For Bleeding Ulcers

(S6E1.1)ENDOSCOPY

ENDOSCOPIC PHOTOGRAPH/ Sketch Endoscopic

photograph mandatory at time of claims.

Sketch cannot be accepted

791Surgical

Gastroenterology

Hepatico Jejunostomy

(S6E11.2)USG, MRCP Post procedure clinical photograph

792Surgical

Gastroenterology

Gb+ Calculi Cbd Stones Or

Dilated Cbd (S6E11.1)USG


improvement and USG

793Surgical

GastroenterologyCholedo choduodenostomy Or Choledocho Jejunostomy (S6E11.3)

USG, MRCP LFT

required for pre authhistopath,CLINICAL PHOTOGRAPH

794Surgical

GastroenterologySplenectomy(S6E12.1)

CT/USG abdomen, lab

investigations


USG,histopath

795Surgical

GastroenterologySplenectomy + Devascularisation + Spleno Renal Shunt(S6E12.2) USG, UGI Scopy BIOPSY,CLINICAL PHOTOGRAPH

796Surgical

Gastroenterology

Spleenectomy For Space

Occupying Lesion(S6E12.3)

CT / USG

BIOPSY MANDATORY AT TIME OF PREAUTHCLINICAL PHOTOGRAPH, USG

797Surgical

GastroenterologyCysto Gastrostomy (S6E14.2) CT/USG abdomen Post procedure clinical photograph, USG

798Surgical

GastroenterologyCysto Jejunostomy (S6E14.1) CT/USG abdomen Post procedure clinical photograph, USG

799Surgical

GastroenterologyRt Hepatectomy(.S6E21) CT, USG CLINICAL PHOTOGRAPH, USG, Biopsy

800Surgical

GastroenterologyLt Hepatectomy(S6E2.2) CT, USG CLINICAL PHOTOGRAPH, USG, Biopsy

801Surgical

GastroenterologySegmentectomy(S6E2.3) CT, USG

CLINICAL PHOTOGRAPH,

USG, Biopsy

802Surgical

GastroenterologyHepato Cellular Carcinoma(Advanced) Radio Frequency Ablation (S6E2.4)BIOPSY, USG/ CT- SCAN, Tumor marker (AFP)

Post procedure clinical photograph, USG, Intra

Op Photo

803Surgical

GastroenterologyHaemangioma Sol Liver Hepatectomy + Wedge Resection(S6E2.5) CT- SCAN, USG BIOPSY, CLINICAL PHOTOGRAPH

804Surgical

Gastroenterology

Hydatid Cyst-Marsupilisation

(S6E2.6)USG / CT- SCAN BIOPSY, CLINICAL PHOTOGRAPH

805Surgical

Gastroenterology

Cyst Excision + Hepatic

Jejunostomy (S6E2.7)CT, USG histopath,CLINICAL PHOTOGRAPH

806Surgical

Gastroenterology

Pancreatic Necrosectomy

(Open) (S6E3.8)

CT- SCAN

serum amylase required for pre authBIOPSY, Post procedure clinical photograph

807Surgical

GastroenterologyWhipples Any Type (S6E3.3) CT/ USG, ERCP, Clinical Photograph BIOPSY,Post procedure clinical photograph, USG

808Surgical

GastroenterologyEnucleation Of Cyst (S6E3.2) CT/USG histopath,CLINICAL PHOTOGRAPH

809Surgical

Gastroenterology

Distal Pancreatectomy

(S6E3.1)

CT serum amylase

required for pre authBIOPSY,Post procedure clinical photograph, USG

810Surgical

Gastroenterology

Central

Pancreatectomy(S6E3.10)CT- SCAN BIOPSY, CLINICAL PHOTOGRAPH

811Surgical

GastroenterologyTriple Bypass(S6E3.4) CT CLINICAL PHOTOGRAPH,USG

812Surgical

GastroenterologyOther Bypasses(S6E3.5) CT CLINICAL PHOTOGRAPH,USG

813Surgical

Gastroenterology

Lap- Pancreatic Necrosectomy

(S6E3.6)CT- SCAN BIOPSY,CLINICAL PHOTOGRAPH

814Surgical

GastroenterologyLateral Pancreaticojejunostomy(Non- Malignant) (S6E3.7) CT- SCAN BIOPSY,CLINICAL PHOTOGRAPH

815Surgical

GastroenterologyDistal Pancreatectomy + Splenectomy (S6E3.9) CT- SCAN BIOPSY,CLINICAL PHOTOGRAPH

816Surgical

GastroenterologyColonic Pull Up (S6E4.1) BIOPSY, ENDOSCOPY, CT- SCAN CLINICAL PHOTOGRAPH,USG

817Surgical

GastroenterologyOesophagectomy (S6E4.2) BIOPSY, ENDOSCOPY, CT- SCAN CLINICAL PHOTOGRAPH,USG

818Surgical

Gastroenterology

Oesophago-Gastrectomy

(S6E4.3)BIOPSY, ENDOSCOPY, CT- SCAN

BIOPSY, ENDOSCOPIC PHOTOGRAPH/ Sketch

Endoscopic photograph mandatory at time of

claims. Sketch cannot be accepted

819Surgical

GastroenterologyLap Heller’S Myotomy (S6E4.4) ENDOSCOPY




820Surgical

GastroenterologyLap Fundoplications (S6E4.5) ENDOSCOPY




821Surgical

GastroenterologyPartial Gastrectomy (S6E5.1) BIOPSY, USG, Endoscopic photograph mandatory histopath,CLINICAL PHOTOGRAPH

822Surgical

GastroenterologyTotal Gastrectomy (S6E5.2) BIOPSY,USG,ENDOSCOPY,CT- SCAN Histopath,Post procedure clinical photograph



Sr.



of Preauth


the time of Claim

823Surgical

Gastroenterology

Truncal Vagotomy + Gastro

Jejunostomy (S6E5.3)USG / CT- SCAN

CLINICAL PHOTOGRAPH Biopsy mandatory at

time of claims

824Surgical

Gastroenterology

Distal Gastrectomy For Gastric

Outlet Obstruction (S6E5.4)BIOPSY,USG,ENDOSCOPY,CT- SCAN BIOPSY,CLINICAL PHOTOGRAPH

825Surgical

Gastroenterology

Surgery For Corrosive Injury

Stomach (S6E5.5)ENDOSCOPY /Sketch BIOPSY, CLINICAL PHOTOGRAPH

826Surgical

GastroenterologyLap Adhesiolysis (S6E6.3) CT- SCAN/X-RAY ABD

Post procedure clinical photograph, USG

Biopsy required at time of claims

827Surgical

GastroenterologyMalrotation (S6E6.2) CT- SCAN/X-RAY ABD


required at time of claims

828Surgical

GastroenterologyVolvulus (S6E6.1) CT- SCAN/X-RAY ABD


required at time of claims

829Surgical

GastroenterologyRight Hemicolectomy (S6E7.1) BIOPSY, ENDOSCOPY, CT- SCAN, COLONOSCOPY BIOPSY,CLINICAL PHOTOGRAPH

830Surgical

GastroenterologyLeft Hemicolectomy (S6E7.2)

BIOPSY, ENDOSCOPY, CT- SCAN,

COLONOSCOPYBIOPSY,CLINICAL PHOTOGRAPH

831Surgical

Gastroenterology

Extended Right

Hemicolectomy (S6E7.3)CT- SCAN/USG COLONOSCOPY BIOPSY,Post procedure clinical photograph, USG

832Surgical

GastroenterologyAnterior Resection (S6E7.4)

BIOPSY, ENDOSCOPY, CT- SCAN,

COLONOSCOPYBIOPSY,CLINICAL PHOTOGRAPH

833Surgical

Gastroenterology

Anterior Resection With

Ileostomy (S6E7.5)CT- SCAN/ USG, COLONOSCOPY BIOPSY,Post procedure clinical photograph, USG

834Surgical

Gastroenterology

Abdomino Perineal

Resection(Non- Malignant) (S6E7.6)BIOPSY, ENDOSCOPY, CT- SCAN, COLONOSCOPY BIOPSY,CLINICAL PHOTOGRAPH

835Surgical

Gastroenterology

Hartman.S Procedure With

Colostomy (S6E7.7)BIOPSY, ENDOSCOPY, CT- SCAN, COLONOSCOPY BIOPSY,CLINICAL PHOTOGRAPH

836Surgical

GastroenterologyI Stage-Sub Total Colectomy + Ileostomy (S6E8.1) COLONOSCOPY BIOPSY, CLINICAL PHOTOGRAPH

837Surgical

GastroenterologyIi Stage-J - Pouch (S6E8.2)

CLINICAL PHOTOGRAPH COLONOSCOPY

MANDATORY AT TIME OF PREAUTHCLINICAL PHOTOGRAPH

838Surgical

Gastroenterology

III Stage-Ileostomy Closure

(S6E8.3)CT Scan contrast/ USG

BIOPSY, Post procedure

clinical photograph, USG

839Surgical

GastroenterologyI Stage- Sub Total Colectomy + Ileostomy + J - Pouch (S6E9.1) COLONOSCOPY BIOPSY, CLINICAL PHOTOGRAPH

840Surgical

GastroenterologyIi Stage- Ileostomy (S6E9.2) COLONOSCOPY CLINICAL PHOTOGRAPH

841Surgical

Oncology

Hemimandibulectomy

(S11J1.10)

BIOPSY, X-RAY AT TIME OF

PREAUTH

HPE, Operative notes, Post procedure clinical

photograph

842Surgical

Oncology

Laryngo Pharyngo

Oesophagectomy (S11J1.9)

BIOPSY, X-RAY AT TIME OF

PREAUTH


photograph

843Surgical

Oncology

Laryngectomy Any Type

(S11J1.8)BIOPSY, clinical & radiological evidence


photograph

844Surgical

Oncology

Parotidectomy Any Type

(S11J1.7)BIOPSY, X- RAY, USG, CLINICAL PHOTOGRAPH

HPE, Operative notes, Post


845Surgical

Oncology

Thyroidectomy Any Type

(S11J1.6)

BIOPSY/FNAC, clinical &

radiological evidence

HPE, Operative notes, Post


846Surgical

Oncology

Maxillectomy Any Type



photograph

847Surgical

OncologyHemiglossectomy (S11J1.4)

BIOPSY,

RADIOLOGICAL EVIDENCE MANDATORY AT TIME

OF PREAUTH


photograph

848Surgical

Oncology

Neck Dissection Any Type



photograph

849Surgical

OncologyWide Excision (S11J1.2) BIOPSY


photograph

850Surgical

OncologyComposite Resection & Reconstruction(S11J1.1)

BIOPSY


OF PREAUTH


photograph

851Surgical

OncologyOrbital Exenteration (S11J2.1) BIOPSY/ CLINICAL AND RADIOLOGICAL EVIDENCE


photograph

852Surgical

Oncology

Maxillectomy + Orbital

Exenteration (S11J2.2)BIOPSY/ CLINICAL AND RADIOLOGICAL EVIDENCE


photograph

853Surgical

Oncology

Maxillectomy + Infratemporal

Fossa Clearance (S11J2.3)BIOPSY/ CLINICAL AND RADIOLOGICAL EVIDENCE


photograph

854Surgical

Oncology

Cranio Facial Resection

(S11J2.4)

BIOPSY/ CLINICAL AND

RADIOLOGICAL EVIDENCE


photograph

855Surgical

Oncology

Resection Of Nasopharyngeal

Tumour (S11J3.1)Biopsy/Clinical and radiological evidence


photograph

856Surgical

Oncology

Palatectomy Any Type

(S11J4.1)Biopsy


photograph

857Surgical

OncologySleeve Resection (S11J5.1) Biopsy


photograph

858Surgical

Oncology

Lateral Temporal Bone

Resection (S11J5.2)

Biopsy/FNAC/ Clinical and

Radiological evidence


photograph

859Surgical

Oncology

Subtotal Temporal Bone

Resection (S11J5.3)




photograph

860Surgical

Oncology

Total Temporal Bone Resection

(S11J5.4)




photograph

861Surgical

Oncology

Submandibular Gland Excision

(S11J6.1)




photograph



Sr.



of Preauth


the time of Claim

862Surgical

OncologyTracheal Resection (S11J7.1) Biopsy, CT


photograph

863Surgical

OncologySternotomy + Superior Mediastinal Dissection (S11J8.1) Biopsy and Radiology (CT)


photograph

864Surgical

OncologyTracheal Resection (S11J8.2) Biopsy, CT


photograph

865Surgical

OncologyParathyroidectomy (S11J9.1) CT, S.PTH, NUCLEAR SCAN


photograph

866Surgical

Oncology

Small Bowel Resection

(S11J10.1)clinical & radiological evidence


photograph

867Surgical

Oncology

Closure Of Ileostomy

(S11J10.2)COLONOSCOPY/Loopogram/Enema


photograph

868Surgical

Oncology

Closure Of colostomy

(S11J10.3)COLONOSCOPY/Loopogram


photograph

869Surgical

Oncology

Abdomino Perineal Resection

(Apr) + Sacrectomy (S11J10.4)BIOPSY, CT, COLONOSCOPY


photograph

870Surgical

Oncology

Posterior Exenteration

(S11J11.1)BIOPSY, CT, COLONOSCOPY


photograph

871Surgical

OncologyTotal Exenteration (S11J11.2) BIOPSY, CT, COLONOSCOPY


photograph

872Surgical

OncologyWhipples Any Type (S11J12.6) BIOPSY, Clinical and radiological evidence


photograph

873Surgical

Oncology

Abdominoperineal Resection

(S11J12.5)CT, BIOPSY


photograph

874Surgical

OncologyAnterior Resection (S11J12.4) CT, BIOPSY


photograph

875Surgical

OncologyColectomy Any Type (S11J12.3) CT/ USG, ENDOSCOPY, BIOPSY


photograph

876Surgical

Oncology

Gastrectomy Any Type

(S11J12.2)CT/ USG, ENDOSCOPY, BIOPSY


photograph

877Surgical

Oncology

Oesophagectomy Any Type

(S11J12.1)CT, ENDOSCOPY, BIOPSY


photograph

878Surgical

OncologyTripple Bypass (S11J12.7) BIOPSY, Clinical and radiological evidence


photograph

879Surgical

Oncology

Other Bypasses- Pancreas

(S11J12.8)BIOPSY, Clinical and radiological evidence


photograph

880Surgical

Oncology

Radical Cholecystectomy

(S11J13.1)BIOPSY, Clinical and radiological evidence


photograph

881Surgical

OncologySplenectomy (S11J14.1) BIOPSY, Clinical and radiological evidence


photograph

882Surgical

Oncology

Resection Of Retroperitoneal

Tumours (S11J15.1)Biopsy, Clinical and radiological evidence


photograph

883Surgical

Oncology

Resection With Reconstruction

(S11J16.2)

Biopsy


OF PREAUTH


photograph

884Surgical

Oncology

Abdominal Wall Tumour

Resection (S11J16.1)

Biopsy


OF PREAUTH


photograph

885Surgical

OncologyBilateral Pelvic Lymph node dissection (S11J17.1) CT, FNAC, BIOPSY


photograph

886Surgical

Oncology

Radical Trachelectomy

(S11J17.2)BIOPSY/ MRI


photograph

887Surgical

Oncology

Radical Vaginectomy

(S11J17.3)BIOPSY/ CT


photograph

888Surgical

OncologyRadical Vaginectomy + Reconstruction (S11J17.4) BIOPSY/ CT


photograph

889Surgical

Oncology

Radical Hysterectomy

+Bilateral Pelvic Lymph Node Dissection (Bplnd) + Bilateral Salpingo

Ophorectomy (Bso) / Ovarian Transposition (S11J18.1)

BIOPSY, CTHPE, Operative notes, Post procedure clinical

photograph

890Surgical

OncologyAnterior Exenteration (S11J18.2) BIOPSY, CT


photograph

891Surgical

OncologyPosterior Exenteration (S11J18.3) BIOPSY, CT


photograph

892Surgical

OncologyTotal Pelvic Exenteration (S11J18.4) BIOPSY,CT


photograph

893Surgical

OncologySupra Levator Exenteration (S11J18.5) BIOPSY,CT


photograph

894Surgical

Oncology

Total Abdominal Hysterectomy(Tah) + Bilateral Salpingo Ophorectomy

(Bso) + Bilateral Pelvic Lymph Node Dissection (Bplnd) + Omentectomy

(S11J19.1)

CT, ENDOMETRIAL BIOPSYHPE, Operative notes, Post procedure clinical

photograph

895Surgical

OncologyChest Wall Resection (S11J20.1) BIOPSY


photograph

896Surgical

OncologyChest Wall Resection + Reconstruction (S11J20.2) BIOPSY


photograph

897Surgical

OncologyLimb Salvage Surgery Without Prosthesis (S11J22.1) BIOPSY


photograph

898Surgical

OncologyLimb Salvage Surgery With Custom Made Prosthesis (S11J22.2) BIOPSY


photograph



Sr.



of Preauth


the time of Claim

899Surgical

Oncology

Limb Salvage Surgery With

Modular Prosthesis (S11J22.3)BIOPSY


photograph

900Surgical

Oncology

Forequarter Amputation

(S11J22.4)BIOPSY


photograph

901Surgical

OncologyHemipelvectomy (S11J22.5) BIOPSY


photograph

902Surgical

Oncology

Internal Hemipelvectomy

(S11J22.6)BIOPSY


photograph

903Surgical

Oncology

Curettage & Bone Cement

(S11J22.7)

BIOPSY / OR CLINICO RADIOLOGICAL C/O

MALIGNANCY


photograph

904Surgical

OncologyBone Resection (S11J22.8) BIOPSY


photograph

905Surgical

Oncology

Shoulder Girdle Resection

(S11J22.9)BIOPSY


photograph

906Surgical

OncologySacral Resection (S11J22.10) BIOPSY Final HPE

907Surgical

Oncology

Partial Nephrectomy

(S11J23.1)RADIOLOGICAL ONDE OF MALIGNANCY


photograph

908Surgical

Oncology

Nephroureterectomy For Transitional Cell Carcinima Of Renal Pelvis

(S11J23.2)PATHOLOGY / URINE CYTOLOGY/ BIOPSY


photograph

909Surgical

Oncology

Radical Nephrectomy

(S11J23.3)RADIOLOGICAL ONDE OF MALIGNANCY


photograph

910Surgical

OncologyEmasculation (S11J23.4) BIOPSY / IMAGING - CTSCAN OR MRI


photograph

911Surgical

OncologyRadical Cystectomy (S11J23.5) BIOPSY, CT ABDO PELVIS


photograph

912Surgical

OncologyOther Cystectomies (S11J23.6) BIOPSY, CT AFP


photograph

913Surgical

OncologyTotal Penectomy (S11J23.7) BIOPSY /CLINICAL PHOTOGRAPH


photograph

914Surgical

OncologyPartial Penectomy (S11J23.8) BIOPSY / CLINICAL PHOTOGRAPH


photograph

915Surgical

Oncology

Inguinal Block Dissection One

Side (S11J23.9)CLINICAL PHOTOGRAPH/ BIOPSY/ FNAC


photograph

916Surgical

Oncology

Radical Prostatectomy

(S11J23.10)IMAGING - MRI, BIOPSY / FLUNDE PET CT


photograph

917Surgical

Oncology

High Orchidectomy

(S11J23.11)TUMOUR MARKERS, CT ABDO PELVIS


photograph

918Surgical

Oncology

Bilateral Orchidectomy

(S11J23.12)BONESCAN, TUMOUR MARKER


photograph

919Surgical

Oncology

Retro Peritoneal Lymph Node Dissection(RPLND) (For Residual Disease)

(S11J24.1)

CT ABDOMEN THORAX PELVIS, TUMOUR

MARKERS


photograph

920Surgical

OncologyAdrenalectomy (S11J24.2)

IMAGING -CT, FDG PET CT, SERUM METARPHINES,

SERUM HORMETAMERPHINES, SERUM CORTIZOL


photograph

921Surgical

OncologyUrinary Diversion (S11J24.3)

INMAGING TO SHOW EVIDENCE OF URINARY

OBSTRUCTION OR INVOLVEMENT OF LOWER

URINARY TRACT IN MALIGNANCY


photograph

922Surgical

Oncology

Retro Peritoneal Lymph Node Dissection Rplnd As Part Of Staging

(S11J24.4)PATHOLOGY IF PRIMARY OR NODES, CT


photograph

923Surgical

Oncology

Anterior Exenteration

(S11J25.1)Biospy, Cystoscopy, CT


photograph

924Surgical

OncologyTotal Exenteration (S11J25.2) BIOPSY,CT


photograph

925Surgical

Oncology

Bilateral Pelvic Lymph Node Dissection(BPLND) for CA Urinary Bladder

(S11J25.3)CT / PATHOLOGY OF PRIMARY


photograph

926Surgical

Oncology

Mediastinal Tumour Resection

(S11J26.1)CECT THORAX, CT BX/ TUMOUR MARKER


photograph

927Surgical

Oncology

Lung Metastatectomy. Solitary

(S11J27.1)CT THORAX


photograph

928Surgical

OncologyLung Metastatectomy. Multiple (S11J27.2) CT THORAX


photograph

929Surgical

Oncology

Sleeve Resection Of Lung

Cancer (S11J27.3)CT THORAX, BIOPSY/ CYTOLOGY


photograph

930Surgical

Oncology

Lung Cancer Lobectomy

(S11J27.5)CT THORAX, BIOPSY/ CYTOLOGY


photograph

931Surgical

Oncology

Lung Cancer Pnumenectomy



photograph

932Surgical

Oncology

Lung Cancer Decortication



photograph

933Surgical

OncologyOesophagectomy With Two Field Lymphadenectomy (S11J28.1) CT THORAX, ENDOSCOPY, BIOPSY


photograph

934Surgical

OncologyOesophagectomy With Three Field Lymphadenectomy (S11J28.2) CT THORAX, ENDOSCOPY, BIOPSY


photograph

935Surgical

OncologyTracheostomy(S11J29.1) CLINICAL PHOTOGRAPH


photograph

936Surgical

OncologySubsternal Bypass (S11J29.2) Clinical indications


photograph



Sr.



of Preauth


the time of Claim

937Surgical

Oncology

Ileotransverse Colostomy

(S11J29.10)CLINICAL PHOTOGRAPH, Biopsy


photograph

938Surgical

OncologyGastro Jejunostomy (S11J29.9) CLINICAL PHOTOGRAPH, Biopsy


photograph

939Surgical

OncologyIntercostal Drainage(Icd) (S11J29.8) CLINICAL PHOTOGRAPH, Biopsy


photograph

940Surgical

Oncology

Suprapubic Cystostomy

(S11J29.7)Clinical indications


photograph

941Surgical

OncologyColostomy(S11J29.6) CLINICAL PHOTOGRAPH, Biopsy


photograph

942Surgical

OncologyIleostomy(S11J29.5) CLINICAL PHOTOGRAPH, Biopsy


photograph

943Surgical

OncologyJejunostomy (S11J29.4) CLINICAL PHOTOGRAPH, Biopsy


photograph

944Surgical

OncologyGastrostomy(S11J29.3) CLINICAL PHOTOGRAPH, Biopsy


photograph

945Surgical

Oncology

Myocutaneous / Cutaneous

Flap (S11J30.1)

Clinical indications, Clinical

Photograph


photograph

946Surgical

Oncology

Micro Vascular Reconstruction

(S11J30.2)

Clinical indications, Clinical

Photograph


photograph

947Surgical

Oncology

Hysterectomy for Tumour

(S11J31.1)BIOPSY /ENDOSCOPY, USG/CT


photograph

948Surgical

Oncology

Radical Hysterectomy for

Tumour (S11J31.2)BIOPSY /ENDOSCOPY, USG/CT


photograph

949Surgical

Oncology

Surgery For Ca Ovary Early

Stage (S11J31.3)BIOPSY /ENDOSCOPY, USG/CT


photograph

950Surgical

Oncology

Surgery For Ca Ovary Advance

Stage(S11J31.4)BIOPSY /ENDOSCOPY, USG/CT


photograph

951Surgical

OncologyVulvectomy (S11J31.5) BIOPSY /ENDOSCOPY, USG/CT


photograph

952Surgical

Oncology

Salpino Oophorectomy

(S11J31.6)BIOPSY /ENDOSCOPY, USG/CT


photograph

953Surgical

OncologyLumpectomy(S11J32.4) BIOPSY, Clinical Photograph


photograph

954Surgical

OncologyWide Excision(S11J32.3) BIOPSY, FNAC, Clinical Photograph, Mamography


photograph

955Surgical

OncologyAxillary Dissection (S11J32.2) BIOPSY, FNAC, Clinical Photograph


photograph

956Surgical

Oncology

Mastectomy Any Type

(S11J32.1)BIOPSY, FNAC, Clinical Photograph


photograph

957Surgical

Oncology

Breast Reconstruction

(S11J32.5)BIOPSY, CLINICAL PHOTOGRAPH


photograph

958Surgical

Oncology

Chest Wall Resection



photograph

959Surgical

Oncology

Skin Tumours Wide Excision



photograph

960Surgical

OncologySkin Tumours Wide Excision + Reconstruction (S11J33.2) BIOPSY, CLINICAL PHOTOGRAPH


photograph

961Surgical

Oncology

Skin Tumours Amputation



photograph

962Surgical

OncologyAmputation (S11J34.3) BIOPSY, CLINICAL PHOTOGRAPH


photograph

963Surgical

OncologyWide Excision + Reconstruction (S11J34.2) BIOPSY, CLINICAL PHOTOGRAPH


photograph

964Surgical

OncologyWide Excision (S11J34.1) BIOPSY, CLINICAL PHOTOGRAPH


photograph

965Surgical

OncologySurgical Correction Of Bronchoplural Fistula Thoracoplasty (S11J36.1) Xray/CT, Biopsy, Clinical indications


photograph

966Surgical

OncologySurgical Correction Of Bronchoplural Fistula. Myoplasty (S11J36.2) Xray/CT, Biopsy, Clinical indications


photograph

967Surgical

Oncology

Surgical Correction Of Bronchoplural Fistula Trans Plural BPF Closure

(S11J36.3)Xray/CT, Biopsy, Clinical indications


photograph

968Surgical

Oncology

Marginal Mandibulectomy

(S11J37.1)

Biopsy,

radiological evidence Mandatory


photograph

969Surgical

Oncology

Segmental Mandibulectomy

(S11J37.2)

Biopsy,

radiological evidence Mandatory


photograph

970Surgical

OncologyTotal Glossectomy + Reconstruction (S11J37.3)

BIOPSY,

USG/Ct scan mandatory


photograph

971Surgical

OncologyFull Thickness Buccal Mucosal Resection & Reconstruction (S11J37.4)

BIOPSY,

USG/Ct scan mandatory


photograph

