UM Guidelines

- A -

Ambulatory Surgery Complications: Observation Care

Applied Behavioral Analysis - For BlueCare Use Only

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

Assistant Surgeon Guidelines

- B -

Bone Excision

Breast Cancer - PALB2 Gene

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

- C -

Carotid Endarterectomy

Cesarean Birth

Cognitive Communication Disorders Rehabilitation

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

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

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

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

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

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

Continuous Positive Airway Pressure (CPAP) Device

Continuous Treatment Team (CTT): Intensive Outpatient Program

Cystic Fibrosis - CFTR Gene and Mutation Panel

- D -

- E -

Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion

Evaluation / Assessment for Applied Behavior Analysis

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

- F -

Foot Orthotics, Custom

- G -

Gastric Restrictive Procedure with Gastric Bypass

Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy

Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy

Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy

- H -

Home Phototherapy Device for Neonatal Hyperbilirubinemia

Hospice Care

Hyperemesis Gravidarum - Case Management

- I -

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

- J -

- K -

- L -

Laminectomy with Rhizotomy

Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy

Liver Transplant

Liver Transplant, Pediatric

- M -

Mastectomy, Complete

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

Mastectomy, Complete, with Tissue Flap Reconstruction

Medical Nutrition Therapy for Dietary Counseling

- N -

- O -

Other Psychiatric Disorders: Intensive Outpatient Program

Other Psychiatric Disorders: Residential Care

- P -

Polysomnography (PSG), Sleep Center

Prostate Cancer - BRCA1 and BRCA2 Genes

Psychosocial Rehabilitation - For BlueCare Use Only

- Q -

- R -

Respite Care, Adult: Residential Care

Respite Care, Child/Adolescent: Residential Care

- S -

Sclerotherapy, Leg Veins

Skilled Nursing Facility/Inpatient Rehabilitation Fax Form

Skilled Nursing Facility (SNF) Levels of Care

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

Smoking Cessation

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

Stereotactic Radiosurgery

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

Substance-Related Disorders, Adult: Inpatient Care

Substance-Related Disorders, Child or Adolescent: Inpatient Care

- T -

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

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

Thoracic Surgery & Pulmonary Disease Intensive Care Admission

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

- U -

- V -

Vaginal Birth

Vaginal Birth - Operative

- W -- X - Y - Z -