| TN 0420 EXTRACORPOREAL MEMBRANE OXYGENATION | ||||||
|---|---|---|---|---|---|---|
| PREAUTH | CLAIMS | |||||
| MIN. CLINICAL SYMPTOMS | MIN. REQUIRED | CRITERIA | DETAILS | % breakup amount - claims | WEIGHTAGE(%) IN CLAIMS AMOUNT | SPECIAL MENTION |
| SEVERE RESP. DISTRESS | CLINICAL PHOTO, CBC, CXR, SaO2 | TOTAL BED DAYS | > 5 | 20 | ||
| DAYS IN ICU | discretion of treating doctor | |||||
| DAYS UNDER VENTILATOR SUPPORT | ||||||
| INVESTIGATIONS | GENERAL WORK UP, ELECTROLYTES | 30 | MANDATORY | |||
| CXR | ||||||
| ABG | ||||||
| COAGULATION PROFILE | ||||||
| TREATMENT | SUPPORTIVE CARE | 50 | ||||
| ECMO | MANDATORY | |||||