Requirements - Priorities of Care
Priorities of care and treatment for health care services will be determined on the basis of relative medical need. Medical procedures which are not funded by Federal medical care payment systems will not be considered as within IHS medical priorities. The IHS will not authorize contract health services (CHS) payment for such procedures not meeting this criteria. Because IHS resources are insufficient to meet-all the needs of the Indian people served, regulations at Code of Federal Regulations, at Title 42, section 136.23(e), "Priorities for contract health services. Require that medical priorities be established governing authorization of CHS.
The application of medical priorities of care is necessary to ensure that the funds provided by Congress for the IHS/CHS funds are adequate to provide services that are authorized in accordance with IHS approved policies and procedures.
Under this authority each Area establishes the medical priority of care that set forth which health care services will be covered by CHS. The medical priority of care is determined as levels, I, II, III, IV, and V. The funding and volume of need by the population have required that most Area can only provided CHS authorization the highest priority medical services - Level I. These medical services are generally only emergency care service, i.e., those necessary to prevent the immediate threat to life, limb, or senses.
The IHS Medical Priorities Levels are:
- Emergent/Acutely Urgent Care Services
- Acute Primary and Preventive Care Services
- Chronic Primary and Secondary Care Services
- Chronic Tertiary Care Services
- Excluded Services
Detailed information on IHS Medical Priorities can be found below:
DATE: September 1995
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PART ONE - APPLICATION OF IHS MEDICAL PRIORITIES
GENERAL
The Indian Health Service (IHS) Medical Priorities will be reviewed annually. Any changes in the definitions, categories, or excluded procedures list will be distributed to all Areas by the Office of Health Programs (OHP).
Each IHS Area will develop Area Medical Priorities that are consistent with IHS Medical Priorities. Each Area will submit copies of their respective contract health services (CHS) medical priorities list to Headquarters East CHS Branch, each time they are updated.
Each Area shall integrate their medical priorities with annual spending plans, since the availability of funds determines the level of medical care that can be provided. It is expected that each service unit will have actively functioning CHS management committees to develop and implement spending plans and authorize payment for CHS referrals in compliance with Area Medical Priorities.
When reviewing appeals and issuing final opinions on CHS care that has been denied because of medical priorities, OHP will take into account the respective Area's medical priorities list.
Where conflict exists, IHS Medical Priorities will take precedence.
Patients and providers will not be issued a payment denial letter for "lack of funds". If the care required is not within medical priorities and the patient is otherwise eligible for CHS, the denial letter shall explain that payment for care is denied because it is not within medical priorities.
REQUESTS FOR PAYMENT WITHOUT PRIOR AUTHORIZATION
When emergency care is performed in non-IHS facilities without prior authorization, a review of the patient's eligibility status, compliance with notification requirements, and clinical information must be performed prior to approving CHS payment. Payment should be authorized only for those cases falling within established medical priorities, and meeting all other CHS requirements.
The condition of the patient and manner in which the patient presented for care should be taken into account. The decision to approve or deny payment should not be based solely on the final diagnosis. The CHS Guidelines for Emergent/Urgent Services", distributed 7/8/94, provides additional guidance regarding this issue.
MEDICAL SERVICES
INCLUSIONS, EXCLUSIONS, AND LIMITATIONS OF THE CHS PROGRAM
- Contingent upon the current level of funding the following services though not exhaustive, may be covered under the CHS program:
- Physician services
- Inpatient hospital services
- Outpatient medical/surgical services including emergency room services at free standing ambulatory or hospital based locations
- Outpatient evaluative and crisis intervention mental health services
- Medical services for substance abuse
- Diagnostic laboratory and diagnostic and therapeutic radiologic services
- Home health services, if within medical priorities (e.g. a cancer patient can be treated at home more cost effectively than being, admitted to a hospital for treatment)
- Preventive health services
- Skilled nursing home services as defined by Medicare regulations
- Optometry services
- Dental services
- Physical medicine and rehabilitative services within medical priorities
- Prescription drugs
- Chiropractic services, for subluxation of the spine as demonstrated by X-Ray, when specifically ordered by a physician
- Acupuncture services when provided by a physician
- Autopsies when ordered by an IHS physician for clinical purposes only
- Services provided in accordance with a Federal court order
- Prosthetic devices
- Medical Laboratory and X-Ray
- Podiatry services
- Transportation and per diem for patient
- Transportation and per diem for escort for patients who are unable to travel without assistance; e.g., children and handicapped adults
- Extended care facilities, refer to Exhibit IX, 25.2M
- EXCLUDED SERVICES
The following services, though not exhaustive, are specifically excluded:
- Services and supplies that are not necessary for the diagnosis and treatment of a covered illness or injury
- Custodial care
- Domiciliary care
- Intermediate nursing home care
- Services and supplies for which the Indian person has no legal obligation to pay or for which no charge would be made if the individual were not eligible for IHS
- Services or supplies furnished by local, State, or other Federal programs
- Abortions as proscribed by regulations at 42 CFR, Subpart F
- Naturopaths
- Burials including other related funeral expenses
- Housekeeper and companion services
- Personal comfort and/or convenience items such as beauty and barber services, radio, telephone, and television
- Services to persons in the custody of local, State, and Federal law enforcement agencies
- Services or costs related to deceased persons who are "dead upon arrival at contract facilities. It is not appropriate to deny ambulance charges for treatment en route to an IHS or contract facility unless the patient has been pronounced dead at the scene by appropriate medical personnel.
Level V (excluded services) includes cosmetic procedures (V.A) and procedures excluded from authorization for CHS payment (V .B).
The OHP will review the list on an annual basis and notify Area CMOs of any additions or deletions. The list is based upon the Medicare Coverage Issuance Manual.
The fiscal intermediary will not pay a claim for a potentially cosmetic procedure listed in Appendix II.A unless approval is received from the CMO. This may be granted if one of the listed procedures, normally considered cosmetic, is necessary for proper mechanical function or psychological reasons.
Payment for excluded procedures listed in Appendix II.B will not be paid by the fiscal intermediary, unless a formal exception has been granted by the OHP (see IHS Circular 93-03, "Cosmetic and Experimental Procedures Review").
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PART TWO -DESCRIPTION OF MEDICAL PRIORITY LEVELS
I. EMERGENT/ACUTELY URGENT CARE SERVICES
Definition: Diagnostic or therapeutic services that are necessary to prevent the immediate death or serious impairment of the health of the individual, and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible health care available and capable of furnishing such services. Diagnosis and treatment of injuries or medical conditions that. if left untreated, would result in uncertain but potentially grave outcomes.
Categories of Services Included (random order):
- Emergency room care for emergent/urgent medical conditions, surgical conditions, or acute trauma
- Emergency inpatient care for emergent/urgent medical conditions, surgical conditions. or acute injury
- Renal replacement therapy, acute and chronic
- Emergency psychiatric care involving suicidal persons or those who are a serious threat to themselves or others
- Services and procedures necessary for the evaluation of potentially life threatening illnesses or conditions
- Obstetrical deliveries and acute perinatal care
- Neonatal care
See Appendix I for examples of specific diagnoses.
II. PREVENTIVE CARE SERVICES
Definition: Primary health care that is aimed at the prevention of disease or disability. This includes services proven effective in avoiding the occurrence of a disease (primary prevention) and services proven effective in mitigating the consequences of an illness or condition (secondary prevention).
Categories of Services Included (random order):
- Routine prenatal care
- Non-urgent preventive ambulatory care (primary prevention)
- Screening for known disease entities (secondary prevention)
- Screening Mammograms
- Public health intervention
The IHS requires a high priority for preventive health care services. Level II services are distinguished from emergency care, sophisticated diagnostic procedures, treatment of acute conditions, and care primarily intended for symptomatic relief or chronic maintenance.
Most services listed as Level II are available at IHS direct care facilities. When these services are purchased using CHS funding, it is usually requested by an IHS or tribal service unit with no direct care capabilities. In addition, IHS direct care facilities may, at times, find it necessary to purchase or defer these types of services, if they are unable to directly provide for any of their patient's preventive health care needs.
ELECTIVE REFERRALS INITIATED BY IHS PROVIDERS
When patients are referred for elective procedures, consultation, outpatient or inpatient care, payment for eligible patients should be authorized only when the care required is medically necessary and falls within established medical priorities. All referrals will be reviewed and approved in a prescribed manner.
The condition of the patient at the time of the referral will influence the ultimate determination of Level III and IV services. In order to determine whether or not the needed care is within established medical priorities the following questions should be considered:
- What is the rate of deterioration of the patient's condition (is the needed service deferrable or non-deferrable)?
- What will be the potential morbidity on the patient if the desired care is not rendered (are there any uncertain but potentially grave outcomes)?
- What is the expected benefit from the evaluation or treatment (will the care likely result in a cure or improvement)?
- Is the procedure experimental or purely cosmetic (is the requested service on the excluded list)'?
Controversial types of therapy shall have a rigorous review. Services such as disc surgery, hysterectomies. tonsillectomies and tonsillectomies, and adenoidectomies, portacaval shunts, obesity surgery, etc., may necessitate a second opinion process established by the Area Chief Medical Officer (CMO).
In general, authorization should be made for only one visit at a time, or for a prescribed number of visits. If additional procedures or care are required, the medical priority of the follow-up request may be different. Patients should be asked to return for another referral.
III. PRIMARY AND SECONDARY CARE SERVICES
Definition: Inpatient and outpatient care services that involve the treatment of prevalent illnesses or conditions that have a significant impact on morbidity and mortality. This involves treatment for conditions that may be delayed without progressive loss of function or risk of life, limb, or senses. It includes services that may not be available at many IHS facilities and/or may require specialty consultation.
Categories of Services Included (random order):
- Scheduled ambulatory services for non-emergent conditions
- Specialty consultations in surgery, medicine, obstetrics, gynecology, pediatrics, ophthalmology, ENT, orthopedics, and dermatology
- Elective, routine surgeries that have a significant impact on morbidity and mortality
- Diagnostic evaluations for non-acute conditions
- Specialized medications not available at an IHS facility, when no suitable alternative exists
IV. CHRON1C TERTIARY AND EXTENDED CARE SERVICES
Definition: Inpatient and outpatient care services that (I) are not essential for initial/emergent diagnosis or therapy, (2) have less impact on mortality than morbidity , or (3) are high cost, are elective, and often require tertiary care facilities. These services are not readily available from direct care IHS facilities. Careful case management by the service unit CHS committee is a requirement, as is monitoring by the Area CMO, or his/her designee. Depending on cost, the referral may require concurrence by the CMO.
Categories of Services Included (random order):
- Rehabilitation care
- Skilled nursing facility (medicare defined)
- Highly specialized medical services/procedures
- Restorative orthopedic and plastic surgery
- Other specialized elective surgery such as obesity surgery
- Elective open cardiac surgery
- Organ transplantation (HCFA approved organs only)
Traditional Native American healing practices
According to IHS policy on traditional healing and religious practices, "when an IHS patient requests assistance in obtaining the services of a native practitioner, every effort will be made to comply. Such efforts might include contacting a native practitioner, providing space or privacy within a hospital room for a ceremony, and/or the authorization of contract health care funds to pay for native healer consultation." For medical priority purposes, these native practitioner services will be equivalent to Level IV services.
V. EXCLUDED SERVICES
Definition: Services and procedures that are considered purely cosmetic in nature, experimental or investigational, or have no proven medical benefit
V.A: Cosmetic Procedures -Payment for certain cosmetic procedures may be authorized if these services are necessary for proper mechanical function or psychological reasons. Approval from the CMO is required.
V.B: Experimental and Other Excluded Services -Payment is not authorized, unless a formal exception is granted by the OHP .
The list of therapies and procedures classified as potentially cosmetic in nature, experimental, or excluded will be reviewed and updated on an annual basis.
Categories of Excluded Services:
- All purely cosmetic (not reconstructive) plastic surgery
- Procedures defined as experimental by the Health Care Financing Administration
- Procedures for which there is no proven medical benefit -procedures listed as "Not Covered" in the Medicare Coverage Issuance Manual, Section 27,200
- Extended care nursing homes (intermediate or custodial care)
- Alternate medical practices (e.g., homeopathy, acupuncture. chemical endarterectomy, natureopathy)
See Appendix II.A for a listing of procedures that are considered to be potentially cosmetic in nature and Appendix II.B for 3. listing of procedures considered to be experimental or otherwise excluded from coverage.
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APPENDIX I.
LEVEL I PRIORITY: EXAMPLES OF DIAGNOSES THAT USUALLY REQUIRE EMERGENT/ACUTELY URGENT CARE SERVICES (NOT AN ALL INCLUSIVE LIST)
Abscess
Airway obstruction
Amputation, traumatic
Anaphylaxis
Appendicitis
Arrh ythrnias
Asthma, acute
Burns
Cholecystitis, acute
Coma
Concussion
Congestive heart failure, decompensated
Dehydration, severe
Delirium tremens
Diabetic ketoacidosis
Drowning, near
Embolism. cerebral or peripheral
Encephalitis
Epididymitis. Acute
Epiglottitis
Eye diseases, acute
Eye injuries
Flail chest
Fractures
Glomerulonephritis, acute
Gunshot wounds
Head injury
Heat exhaustion and prostration
Hemoptysis
Hemorrhage
Hepatic encephalopathy
Hernia, strangulated or ruptured
Hypercalcemia
Hypertension, crisis or emergency
Lacerations
Meningitis
Menorrhagia. profuse
Migraine, acute attacks
Musculoskeletal trauma. Acute
Myocardial ischemia, acute
Myocardial infarctions
Obstetrical emergencies
Pancreatitis
Pelvic inflammatory disease
Peritonitis
Pneumonia, acute
Pneumothorax
Poisoning
Premature infant
Pulmonar embolism
Pulmonar edema
Puncture or stab wounds
Rape, alleged, examination
Renal lithiasis, acute
Renal failure, acute
Respiratory failure
Sepsis
Shock
Spinal colurn injuries
Suicide attempt
Urinary retention, obstruction
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APPENDIX II.
LEVEL V.A: COSMETIC PROCEDURES
Argon Laser Treatment for Congenital Hemangiomas
Topical Chemotherapy (Total Face and/or Neck)
Mastectomy for Gynecomastia
Mastectomy, Subcutaneous with Delayed Prosthetic Implant
Removal of Mammary Implant Material
Reconstruction of Nipple and/or Areola
Revision (Release of Scar Contracture) of Breast, Following Mammoplasty
Blepharoptosis Repair
Tattooing
Subcutaneous Injection of "Filling" Material (i.e. Collagen)
Insertion of Tissue Expanders
Dermabrasion
Abrasion (i.e. Keratoses)
Chemical Peel
Salabrasion
Cervicoplasty
Rhytidectomy
Excision Excessive Skin and Subcutaneous Tissue (Including Lipectomy)
Suction Assisted Lipectomy
Cryotherapy for Acne
Electrolysis Epilation
Mastopexy
Reduction Mammoplasty
Augmentation Mammoplasty
Breast Reconstruction
Applicarion of Halo Type Appliance for Maxillofacial Fixation
Application of Interdental Fixation Device for Condition other than Fracture or Dislocation
Reconstrution of Midface
Reconstruction of Mandibular Ramus
Osteoplasty of Facial Bones
Bone Graft to Nasal, Maxillary and Malar Areas
Cartilage Graft to Face, Chin, Nose or Ear
Treatment of Craniofacial Separation
Interdental Wiring for Conditions other than Fractures
Rhinoplasty
Vermilionectomy
Resection of Lip
Destruction of Lesion of Scar
Gingivectomy
Repair of Ectropion
Blepharoplasty
LEVEL V.B PRIORITY: EXPERIMENTAL (INVESTIGATIONAL) AND OR EXCLUDED PROCEDURES NOT COVERED BY THE CHS PROGRAM
Radial Keratotomy I:Sec. 35-54)
Extracranial-Intracranial Bypass (Sec. 35-37)
Insert Gastric Bubble (Sec. 35-86 and MCE)
Auxiliary Liver Transplant (~ICE)
Implant Bladder S timulator r.Sec. 65-11 and \1CE)
Replace Bladder Stimulator \ylCE)
Laetrile (Sec. .+5-10)
Cellular Therapy (Fresh Cell) (Sec 35-5)
IV Chelation Therapy (Chemical Endarterectomy) (Sec. 35-6.+, .+5-.:0)
Human Tumor Stem Cell Assay (Sec. 50-..+ 1 )
Omnicardiograrn/C3Idiointegram (Set:. 50-~7)
Acupuncture (Sec. 35-8)
Punch Graft for Hair Transplant
Invasive Electrical Bone Growth Stimulation (Sec. 35-.+8 with criteria)
Percutaneous Electrical Bone Growth Stimulation (Sec. 35-48 with criteria)
Insertion of Implantable Infusion Pump (Sec. 60-14 with criteria)
Therapeutic Apheresis (Sec. 35-60 with criteria)
Bone Marrow Harvesting for Transplantation (Sec. 35-30 with criteria)
Gastric By-Pass for Morbid Obesity (Sec. 35-40 with criteria)
Intestinal By-Pass for Morbid Obesity (Sec. 35-33)
Pancreatectomy with Transplant (Sec. 35-82)
Insertion of Testicular Prosthesis (Sec. 35-61)
Intersex Surgery Male to Female (Sec. 35-61)
In-vitro Fertilization
Intersex Surgery Female to Male (Sec. 35-61)
Follicular Puncture for Oocyte Retrieval
Culture and Fertilization of Oocyte
Embryo Transfer
Gamete or Zygote Intrafallopian Transfer, Any Method
Implantation of Neurostimulator Electrodes (Sec. 35-20, 65-8)
Percutaneous Implantation of Neurostimulator Electrodes (Sec. 35-46, 65-8)
TENS (Sec. 35-46, 45-19 with criteria)
Keratornileusis (Sec. 35-54)
Keratophakia (Sec. 35-54)
Radial Keratotomy/Keratoplasty (Sec. 35-54)
Ear Piercing
Tinnitus Masking (Sec. 35-63)
Cochlear Device Implantation (Sec. 65-14 w/criteria; both IHS and Medicare have age criteria)
Hyperthermia (Sec. 35-49 with criteria)
Bone Density Study (Sec. 50-4-1. with criteria)
Biofeedback (Sec. 35-27 with criteria)
Esophageal Acid Reflux Testing (Sec. 35-83)
Corneal Endothelial Microscopy (Sec. 50-38 with criteria)
Plethysmography (Sec. 50-6 with criteria)
Ambulatory Blood Pressure Monitoring (Sec. 50-42)
Polysomnography (Sec. 60-17)
Hyerbaric Oxygen Therapy (Sec. 35-10 with criteria)
OTHER
Artificial Hearts (Sec. 65-15)
Colonic irrigation (Sec. 35-1 )
Cytotoxic Food Testing (Sec. 50-2)
Electric Aversion Therapy (Sec. 35-23.1)
Electrosleep Therapy (Sec. 35-18)
Electrotherapy for Facial Nerve Palsy (Sec. 35- 72)
External Counterpulsation (Sec. 35- 74)
Gasttic Freezing (Sec. 35-65)
Hair Analysis (Sec. 50-24)
Electric Nerve Stimulation for Motor Dysfunction (Sec. 35-20)
Challenge Ingestion Food Testing (Sec. 50-22 with criteria)
Heat Treatment for Pulmonary Conditions
Hemodialysis for Treattnent of Schizophrenia (Sec. 35-51)
Human Tumor Stem Cell Drug Sensitivity Assays (Sec. 50-41)
Intestinal Transplantation
Intravenous Histamine Therapy (Sec. 35-19)
Joint and Ligament Sclerosing Therapy (Sec. 35-13)
Ponable Hand Held X-Ray Instruments
Prolotherapy (Sec. 35-13)
Pulmonary Embolectomy, Transvenous (catheter) (Sec. 35-55)
Thermogenic Therapy (Sec. 35-6)
Tattoo Removal
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