Clinical Determinations and Indications library
Overview
This library contains published clinical determinations and indications that community providers may use as a resource to help determine if a Veteran meets VA clinical criteria for services and procedures delivered in the community.
Use of this content indicates your agreement and acceptance to the terms and conditions listed in the End User Agreement to Access Library of Clinical Determinations and Indications.
Terms and definitions
Each clinical determination and indication contains the following terms and associated definitions:
- Effective date: Date the community care medical policy is effective.
- Exclusion criteria: Characteristics that disqualify prospective Veterans from care pathways or prescriptions.
- Experimental or Investigational: A treatment, procedure, equipment, drug, or service that has not been determined to be medically effective for the condition being treated but may be part of a research study to evaluate if the condition improves with use.
- CDI number: A unique ID code that can be used to find the CDI separate from the CDI name.
- Facility: The service is performed in a facility setting (i.e., hospital, ambulatory or surgical center).
- Facility type: Hospital or other institution where outpatient and inpatient services are performed.
- FDA approval: To receive U.S. Food and Drug Administration (FDA) approval, drug manufacturers must conduct testing and submit their data to FDA. FDA may approve the drug if the agency determines the benefits of the drug outweigh the risks for intended use.
- Locality description: Place of service locality (e.g., city, county).
- Medical necessity: Health care services that can be justified as reasonable, necessary and appropriate based on evidence-based clinical standards of care.
- Medicare carrier: Identification number assigned by Centers of Medicare and Medicaid Services (CMS) to a carrier (Medicare Administrative Contractor) authorized to process claims from a physician or supplier.
- Medicare locality: Identification number assigned by the CMS for a locality where care is received.
- Non-facility: The service is performed in a non-facility setting (i.e., physician’s office or outpatient clinic).
- Procedure: Current Procedural Terminology (CPT) / Current Dental Terminology (CDT) / Healthcare Common Procedure Coding System (HCPCS) codes are industry standard codes used to identify specific surgical, medical, or diagnostic interventions.
- Procedure code modifier: Supplemental information or “adjust care” descriptions to provide extra detail concerning a procedure or service.
Complementary & Integrative Health (CIH)
Dentistry
Dermatology
Gastroenterology / Urology
- Computed Tomography (CT) Colonography / Virtual Colonoscopy
- Fecal Microbiota Products for Clostridioides difficile Infections
- Intragastric Balloon
- Metabolic and Bariatric Surgery
- Prostate-Specific Membrane Antigen Positron Emission Tomography Scan for Prostate Cancer
- Routine Colorectal Cancer Screening
- Sacral Neuromodulation
- Transurethral Water Vapor Thermal Therapy for Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia
- Transurethral Waterjet Ablation for Benign Prostatic Hyperplasia
Miscellaneous
Nuclear Medicine / Oncology / Radiation Oncology
- Intensity Modulated Radiation Therapy Using Photons
- Lutetium-177 (Lu177) PSMA-617, Vipivotide Tetraxetan (Pluvicto)
- Low-Dose CT Scan for Lung Cancer Screening
- Prostate-Specific Membrane Antigen Positron Emission Tomography Scan for Prostate Cancer
- Proton Beam Therapy
- Tumor Treating Fields (TTFs) Therapy
Orthopedics / Podiatry / Amputation
- Allograft Injection for Degenerative Disc Disease
- Dextrose Prolotherapy for Musculoskeletal Pain
- Discseel (Fibrin Sealant Injection)
- Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
- Minimally Invasive and Open Sacroiliac Joint Fusion / Stabilization
- Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA) Implant System for Transfemoral Amputations
- Spinal Fusion Surgery
- Total/Partial Knee Arthroplasty
Orthopedics / Podiatry / Amputation
- Allograft Injection for Degenerative Disc Disease
- Dextrose Prolotherapy for Musculoskeletal Pain
- Discseel (Fibrin Sealant Injection)
- Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
- Minimally Invasive and Open Sacroiliac Joint Fusion / Stabilization
- Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA) Implant System for Transfemoral Amputations
- Spinal Fusion Surgery
- Total/Partial Knee Arthroplasty
Pain Management / Physical Medicine & Rehabilitation (PM&R)
- Allograft Injection for Degenerative Disc Disease
- Bioimpedance Devices for Detection of Lymphedema
- Dextrose Prolotherapy for Musculoskeletal Pain
- Discseel (Fibrin Sealant Injection)
- Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
- Ketamine for Chronic Pain
- Medical Massage Therapy
- Pneumatic Compression Devices for Lymphedema
- Spinal Fusion Surgery
Surgery
- Allograft Injection for Degenerative Disc Disease
- Autologous Chondrocyte Implantation
- Balloon Sinuplasty
- Bioimpedance Devices for Detection of Lymphedema
- Corneal Collagen Cross-Linking
- Cryoablation for Malignant Breast Tumors
- Functional Endoscopic Sinus Surgery (FESS)
- Intragastric Balloon
- Metabolic and Bariatric Surgery
- Micro-Invasive Glaucoma Surgery
- Minimally Invasive and Open Sacroiliac Joint Fusion / Stabilization
- Mitral Valve Transcatheter Edge-to-Edge Repair
- Sacral Neuromodulation
- Spinal Fusion Surgery
- Thread Carpal Tunnel Release
- Total Artificial Heart
- Total/Partial Knee Arthroplasty
Women’s Health / Gynecology / Obstetrics
Terms and definitions
Each clinical determination and indication contains the following terms and associated definitions:
- Effective date: Date the community care medical policy is effective.
- Exclusion criteria: Characteristics that disqualify prospective Veterans from care pathways or prescriptions.
- Experimental or Investigational: A treatment, procedure, equipment, drug, or service that has not been determined to be medically effective for the condition being treated but may be part of a research study to evaluate if the condition improves with use.
- CDI number: A unique ID code that can be used to find the CDI separate from the CDI name.
- Facility: The service is performed in a facility setting (i.e., hospital, ambulatory or surgical center).
- Facility type: Hospital or other institution where outpatient and inpatient services are performed.
- FDA approval: To receive U.S. Food and Drug Administration (FDA) approval, drug manufacturers must conduct testing and submit their data to FDA. FDA may approve the drug if the agency determines the benefits of the drug outweigh the risks for intended use.
- Locality description: Place of service locality (e.g., city, county).
- Medical necessity: Health care services that can be justified as reasonable, necessary and appropriate based on evidence-based clinical standards of care.
- Medicare carrier: Identification number assigned by Centers of Medicare and Medicaid Services (CMS) to a carrier (Medicare Administrative Contractor) authorized to process claims from a physician or supplier.
- Medicare locality: Identification number assigned by the CMS for a locality where care is received.
- Non-facility: The service is performed in a non-facility setting (i.e., physician’s office or outpatient clinic).
- Procedure: Current Procedural Terminology (CPT) / Current Dental Terminology (CDT) / Healthcare Common Procedure Coding System (HCPCS) codes are industry standard codes used to identify specific surgical, medical, or diagnostic interventions.
- Procedure code modifier: Supplemental information or “adjust care” descriptions to provide extra detail concerning a procedure or service.