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Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Absolute Total Care Clinical Policy Manual apply to Absolute Total Care members. Policies in the Absolute Total Care Clinical Policy Manual may have either an Absolute Total Care or a “Centene” heading.  Absolute Total Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which an Absolute Total Care clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Absolute Total Care. In addition, Absolute Total Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Absolute Total Care.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z
Abortions (PDF) Intradiscal Steroid Injections for Pain Management (PDF) Retrospective Review for Services Requiring Authorization (PDF)

ADHD Assessment and Treatment (PDF) - Effective until 12/31/2018

ADHD Assessment and Treatment (PDF) - Effective 1/1/2019

Laser Skin Treatment (PDF) Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF) - Effective 9/1/2020 
Allergy Testing (PDF) Low-Frequency Ultrasound Wound Therapy (PDF) Single Case Agreements (PDF)
Ambulatory EEG (PDF) Measure Serum 1,25 Vitamin D (PDF) Sterilization and Hysterectomies (PDF)
Bariatric Surgery (PDF) Mechanical Stretch Devices (PDF) Sacroiliac Joint Interventions for Pain Management (PDF)
Bronchial Thermoplasty (PDF) Medical Mgmt Physician Peer-To-Peer Delegation Policy (PDF) Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Cardiac Biomarker Testing for Acute MI (PDF) Nerve Blocks for Pain Management (PDF) Short Inpatient Hospital Stay (PDF) - Effective 11/15/2020
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) Out of Network Referrals (PDF) Thyroid Testing in Pediatrics (PDF) - Effective 9/1/2020
Clinical Information & Documentation (PDF) Paclitaxel, Protein-Bound (Abraxane) (PDF) Timeliness of UM Decisions and Notifications (PDF)
Diagnosis of Vaginitis (PDF) Physical, Occupational, Speech Therapy (PDF) Tracking Disclosure of InterQual Criteria (PDF)
Digital Analysis of EEGs (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) - Effective 1/1/2021 Transcranial Magnetic Stimulation (PDF)
DNA Analysis of Stool (PDF) PROM Testing (PDF) - Effective 9/1/2020 Transition of Care (PDF)
EEG in Evaluation of Headache (PDF) Proton and Neutron Beam Therapy (PDF) Trigger Point Ingections for Pain Management (PDF)
Emergency Services (PDF)   Ultrasound in Pregnancy (PDF)
Endometrial Ablation (EA) (PDF)   Urodynamic Testing (PDF)
EpiFix Wound Treatment (PDF)   Visual Field Testing (PDF) - Effective 9/1/2020
Evoked Potentials (PDF)   Vitamin D Testing in Children (PDF) - Effective 9/1/2020
Extended Opthalmoscopy (PDF) - Effective 9/1/2020   Wheelchair Seating (PDF)
External Ocular Photography (PDF) - Effective 9/1/2020   Wireless Motility Capsule (PDF)
Facet Joint Interventions for Pain Management (PDF)    
Fecal Calprotectin Assay (PDF)    
FeNo Testing (PDF)    
Fluorescein Angiography (PDF) - Effective 9/1/2020    
Fundus Photography (PDF) - Effective 9/1/2020    
Gonioscopy (PDF) - Effective 9/1/2020    
H Pylori Testing (PDF)    
Holter Monitors (PDF)    
Homocysteine Testing (PDF)    
A-H I-Q R-Z

ADHD Assessment and Treatment (PDF) - Effective until 12/31/2018

ADHD Assessment and Treatment (PDF) - Effective 1/1/2019

Intradiscal Steroid Injections for Pain Management (PDF) Sacroiliac Joint Interventions for Pain Management (PDF)
Allergy Testing (PDF) Laser Skin Treatment (PDF) Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Ambulatory EEG (PDF) Low-Frequency Ultrasound Wound Therapy (PDF) Short Inpatient Hospital Stay (PDF) - Effective 11/15/2020
Bronchial Thermoplasty (PDF) Measure Serum 1,25 Vitamin D (PDF) Transcranial Magnetic Stimulation (PDF)
Cardiac Biomarker Testing for Acute MI (PDF) Mechanical Stretch Devices (PDF) Trigger Point Ingections for Pain Management (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) Nerve Blocks for Pain Management (PDF) Ultrasound in Pregnancy (PDF)
Diagnosis of Vaginitis (PDF) Paclitaxel, Protein-Bound (Abraxane) (PDF) Urodynamic Testing (PDF)
Digital Analysis of EEGs (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) - Effective 1/1/2021 Wheelchair Seating (PDF)
DNA Analysis of Stool (PDF) PROM Testing (PDF) - Effective 9/1/2020 Wireless Motility Capsule (PDF)
EEG in Evaluation of Headache (PDF) Proton and Neutron Beam Therapy (PDF)  
Endometrial Ablation (EA) (PDF)    
EpiFix Wound Treatment (PDF)    
Evoked Potentials (PDF)    
Facet Joint Interventions for Pain Management (PDF)    
Fecal Calprotectin Assay (PDF)    
FeNo Testing (PDF)    
H Pylori Testing (PDF)    
Holter Monitors (PDF)    
Homocysteine Testing (PDF)    
A-H I-Q R-Z

ADHD Assessment and Treatment (PDF) - Effective until 12/31/2018

ADHD Assessment and Treatment (PDF) - Effective 1/1/2019

Intradiscal Steroid Injections for Pain Management (PDF) Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF)- Effective 9/1/2020 
Allergy Testing (PDF) Laser Skin Treatment (PDF) Sacroiliac Joint Interventions for Pain Management (PDF)
Ambulatory EEG (PDF) Low-Frequency Ultrasound Wound Therapy (PDF) Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Bronchial Thermoplasty (PDF) Measure Serum 1,25 Vitamin D (PDF) Short Inpatient Hospital Stay (PDF) - Effective 11/15/2020
Cardiac Biomarker Testing for Acute MI (PDF) Mechanical Stretch Devices (PDF) Thyroid Testing in Pediatrics (PDF) - Effective 9/1/2020
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) Nerve Blocks for Pain Management (PDF) Transcranial Magnetic Stimulation (PDF)
Diagnosis of Vaginitis (PDF) Paclitaxel, Protein-Bound (Abraxane) (PDF) Trigger Point Ingections for Pain Management (PDF)
Digital Analysis of EEGs (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) - Effective 1/1/2021 Ultrasound in Pregnancy (PDF)
DNA Analysis of Stool (PDF) Proton and Neutron Beam Therapy (PDF) Urodynamic Testing (PDF)
EEG in Evaluation of Headache (PDF)   Visual Field Testing (PDF) - Effective 9/1/2020
Endometrial Ablation (EA) (PDF)   Vitamin D Testing in Children (PDF)- Effective 9/1/2020
EpiFix Wound Treatment (PDF)   Wheelchair Seating (PDF)
Evoked Potentials (PDF)   Wireless Motility Capsule (PDF)
Extended Opthalmoscopy (PDF) - Effective 9/1/2020    
External Ocular Photography (PDF) - Effective 9/1/2020    
Facet Joint Interventions for Pain Management (PDF)    
Fecal Calprotectin Assay (PDF)    
FeNo Testing (PDF)    
Fluorescein Angiography (PDF) - Effective 9/1/2020    
Fundus Photography (PDF) - Effective 9/1/2020    
Gonioscopy (PDF) - Effective 9/1/2020    
H Pylori Testing (PDF)    
Holter Monitors (PDF)    
Homocysteine Testing (PDF)    
A-H I-Q R-Z
25-Hydroxyvitamin D Testing (PDF) Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) Radial Head Implant (PDF)
Acupuncture (PDF)

Inhaled Nitric Oxide (PDF)

Reduction Mammoplasty and Gynecomastia Surgery (PDF)
ADHD Assessment and Treatment (PDF)

Intensity-Modulated Radiotherapy (PDF)

Sacroiliac Joint Fusion (PDF)
Allergy Testing (PDF)

Intestinal and multivisceral transplant (PDF)

Sacroiliac Joint Interventions for Pain Management (PDF)
Allogeneic Hematopoietic Cell Transplants (PDF)

Intradiscal Steroid Injections for Pain Management (PDF)

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF) - Effective 9/1/2020 
Ambulatory EEG (PDF)

Laser Skin Treatment (PDF)

Sclerotherapy for Varicose Veins (PDF)
Ambulatory Surgery Center Optimization (PDF)

Long Term Care Placement Criteria (PDF)

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Applied Behavioral Analysis for Autism (PDF)

Low-Frequency Ultrasound Wound Therapy (PDF)

Short Inpatient Hospital Stay (PDF) - Effective 11/15/2020
Articular Cartilage Defect Repairs (PDF)

Lung Transplantation (PDF)

Sickle Cell Disease Observation (PDF)
Assisted Reproductive Technology (PDF)

Lysis of Epidural Lesions (PDF)

Spinal Cord Stimulation (PDF)
Balloon Sinus Ostial Dilation (PDF)

Measure Serum 1,25 Vitamin D (PDF)

Stereotactic Body Radiation Therapy (PDF)
Bariatric Surgery (PDF)

Mechanical Stretch Devices (PDF)

Tandem Transplant (PDF)
Biofeedback (PDF)

Medical Necessity Criteria (PDF)

Testing for rupture of fetal membranes (PDF)
Bone-anchored Hearing Aid (PDF)

Multiple Sleep Latency Testing (PDF) Testing for Select Genitourinary Conditions (Previously Diagnosis of Vaginitis) (PDF) - Effective 9/1/2020
Bronchial Thermoplasty (PDF)

Neonatal Abstinence Syndrome Guidelines (PDF) Therapy Services (PTOTST) (PDF)
Cardiac Biomarker Testing for Acute MI (PDF)

Neonatal Sepsis Management Guidelines (PDF) Thyroid Testing in Pediatrics (PDF)
Carrier Screening in Pregnancy (PDF)

Nerve Blocks for Pain Management (PDF) Total Artificial Heart (PDF)
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)

NICU Apnea Bradycardia Guidelines (PDF) Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Cell-free Fetal DNA Testing (PDF)

NICU Discharge Guidelines (PDF) Transcatheter Closure of Patent Foramen Ovale (PFO) (PDF)
Clinical Trials (PDF)

Nonmyeloablative allogeneic stem cell transplant (PDF) Transcranial Magnetic Stimulation (PDF)
Cochlear Implant Replacements (PDF)

OB Home Health Programs (PDF) Trigger Point Ingections for Pain Management (PDF)
Cosmetic and Reconstructive Surgery (PDF)

Optic Nerve Decompression Surgery (PDF) Ultrasound in Pregnancy (PDF)
Dental Anesthesia (PDF)

Outpatient Testing for Drugs of Abuse (PDF) Urinary Incontinence Devices and Treatments (PDF)
Diagnosis of Vaginitis (PDF)

Paclitaxel, Protein-Bound (Abraxane) (PDF) - Effective 9/1/2020 Urodynamic Testing (PDF)
Digital Analysis of EEGs (PDF)

Pancreas Transplantation (PDF) Vagus Nerve Stimulation (PDF)
Disc Decompression Procedures (PDF)

Panniculectomy (PDF) Ventricular Assist Devices (PDF)
Discography (PDF)

Pediatric Heart Transplant (PDF) Ventriculectomy and Cardiomyoplasty (PDF)
DNA Analysis of Stool (PDF)

Pediatric Liver Transplant (PDF) Visual Field Testing (PDF) - Effective 9/1/2020
Donor Lymphocyte Infusion (PDF)

Percutaneous LAAD Stroke Prevention (PDF) Vitamin D Testing in Children (PDF) - Effective 9/1/2020
Durable Medical Equipment (DME) (PDF)

Posterior Nerve Stimulation for Voiding Dysfunction (PDF) Wheelchair Seating (PDF)
EEG in Evaluation of Headache (PDF)

Preventive Health and Clinical Practice Guideline Policy (PDF) Wireless Motility Capsule (PDF)
Electric Tumor Treating Fields (PDF)

PROM Testing (PDF) - Effective 9/1/2020 Zika Virus Testing (PDF)
Endometrial Ablation (EA) (PDF)

Proton and Neutron Beam Therapy (PDF)  
EpiFix Wound Treatment (PDF)

   
Essure Removal (PDF)

   
Evoked Potentials (PDF)

   
Experimental Technologies (PDF)

   
Extended Opthalmoscopy (PDF) - Effective 9/1/2020    
External Ocular Photography (PDF) - Effective 9/1/2020    
Facet Joint Interventions for Pain Management (PDF)

   
Fecal Calprotectin Assay (PDF)

   
Fecal Incontinence Treatments (PDF)

   
Ferriscan R2-MRI (PDF)

   
Fertility Preservation (PDF)

   
Fetal Surgery In Utero (PDF)

   
FeNo Testing (PDF)

   
Fluorescein Angiography (PDF) - Effective 9/1/2020    
Functional MRI (PDF)    
Fundus Photography (PDF) - Effective 9/1/2020    
Gastric Electrical Stimulation (PDF)

   
Gender Reassignment Surgery (PDF)

   
Genetic Testing (PDF)

   
Gonioscopy (PDF) - Effective 9/1/2020    
H Pylori Testing (PDF)

   
Heart-Lung Transplant (PDF)

   
Holter Monitors (PDF)

   
Home Birth (PDF)

   
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)

   
Homocysteine Testing (PDF)

   
Hospice Services (PDF)

   
Hyperbaric Oxygen Therapy (PDF)

   
Hyperemesis Gravidarum Treatment (PDF)

   
Hyperhidrosis Treatments (PDF)

   

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Absolute Total Care Payment Policy Manual apply with respect to Absolute Total Care members. Policies in the Absolute Total Care Payment Policy Manual may have either an Absolute Total Care or a “Centene” heading.  In addition, Absolute Total Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Absolute Total Care.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z
3-Day Payment Window (PDF) Inpatient Consultation (PDF) Review of Acute Care Readmissions within 30 Calendar Days (PDF)
30-Day Readmission (PDF) - Effective 9/1/2020 Inpatient Only Procedures (PDF) Renal Hemodialysis (PDF) - Effective 1/1/21
Add on Code Billed Without Primary Code (PDF) IV Hydration (PDF) Robotic Surgery (PDF)
Assistant Surgeon (PDF) Lab Quantity Limits (PDF) - Effective 9/1/2020 Same Day Visits (PDF)
Bilateral Procedures (PDF) Maximum Units (PDF) Sleep Studies Place of Service (PDF) - Effective 9/1/2020
Cerumen Removal (PDF) Modifier -25 clinical validation Status "B" Bundled Services (PDF)
Cosmetic Procedures (PDF) Modifier -59 clinical validation (PDF) Status P Bundled Services (PDF)
Distinct Procedural Modifiers (PDF)
Modifier DOS Validation (PDF) Supplies Billed on Same Day as Surgery (PDF)
Duplicate Primary Code Billing (PDF) Multiple CPT Code Replacement (PDF) Transgender Related Services (PDF)
EM Bundling Edits (PDF) Modifier to Procedure Code Validation (PDF) Unbundled Professional Services (PDF)
Global Maternity Billing (PDF) Multiple Procedure Reduction: Ophthalmology (PDF) - Effective 1/1/21 Unbundled Surgical Procedures (PDF)
Hospital Visit Codes Billed with Labs (PDF) Multiple Procedure Payment Reduction for Therapeutic Services (PDF) - Effective 1/1/21 Unlisted Procedure Codes (PDF)
  NCCI Unbundling (PDF) Urine Specimen Validity Testing (PDF)
  Never Paid Events (PDF) Wheelchair Accessories (PDF)
  New Patient (PDF)  
  Non-Emergent ER Services (PDF)  
  Outpatient Consultation (PDF)  
  Pelvic and Transabdominal US (PDF)  
  Physician's Consultation Services (PDF) - Effective 9/1/2020  
  Physician's Office Lab Testing (PDF)  
  Physician Visit Codes Billed with Labs (PDF)  
  Place of Service Mismatch (PDF)  
  Post-Operative Visits (PDF)  
  Pre-Operative Visits (PDF)  
  Problem-Oriented Visits with Preventative Visits (PDF) - Effective 9/1/2020  
  Problem-Oriented Visits with Surgical Procedures (PDF) - Effective 9/1/2020  
  Professional Component (PDF)  
  Pulse Oximetry (PDF)  
 
A-H I-Q R-Z
3-Day Payment Window (PDF) Inpatient Consultation (PDF) Renal Hemodialysis (PDF) - Effective 1/1/21
30-Day Readmission (PDF) - Effective 9/1/2020 Inpatient Only Procedures (PDF) Robotic Surgery (PDF) - Effective 9/1/2020
Add on Code Billed Without Primary Code (PDF) IV Hydration (PDF) Same Day Visits (PDF)
Assistant Surgeon (PDF) Lab Quantity Limits (PDF) - Effective 9/1/2020 Sleep Studies Place of Service (PDF) - Effective 9/1/2020
Bilateral Procedures (PDF) Maximum Units (PDF) Status "B" Bundled Services (PDF)
Cerumen Removal (PDF) Modifier -25 clinical validation Status P Bundled Services (PDF)
Cosmetic Procedures (PDF) Modifier -59 clinical validation (PDF) Supplies Billed on Same Day as Surgery (PDF)
Distinct Procedural Modifiers (PDF) Modifier DOS Validation (PDF) Transgender Related Services (PDF)
Duplicate Primary Code Billing (PDF) Modifier to Procedure Code Validation (PDF) Unbundled Professional Services (PDF)
EM Bundling Edits (PDF) Multiple CPT Code Replacement (PDF) Unbundled Surgical Procedures (PDF)
Global Maternity Billing (PDF) Multiple Procedure Payment Reduction for Therapeutic Services (PDF) - Effective 1/1/21 Unlisted Procedure Codes (PDF)
Hospital Visit Codes Billed with Labs (PDF) Multiple Procedure Reduction: Ophthalmology (PDF) - Effective 1/1/21 Urine Specimen Validity Testing (PDF)
  NCCI Unbundling (PDF) Wheelchair Accessories (PDF)
  Never Paid Events (PDF)  
  New Patient (PDF)  
  Non-Emergent ER Services (PDF)  
  Outpatient Consultation (PDF)  
  Pelvic and Transabdominal US (PDF)  
  Physician's Consultation Services (PDF) - Effective 9/1/2020  
  Physician's Office Lab Testing (PDF)  
  Physician Visit Codes Billed with Labs (PDF)  
  Place of Service Mismatch (PDF)  
  Post-Operative Visits (PDF)  
  Pre-Operative Visits (PDF)  
  Problem Oriented Visits with Preventative Visits (PDF)  
  Problem Oriented Visits with Surgical Procedures (PDF)  
  Professional Component (PDF)  
  Pulse Oximetry (PDF)  
A-H I-Q R-Z
30-Day Readmission (PDF) - Effective 9/1/2020 Inpatient Consultation (PDF) Robotic Surgery (PDF) - Effective 9/1/2020
Add on Code Billed Without Primary Code (PDF)
Inpatient Only Procedures (PDF) Review of Acute Care Readmissions within 30 Calendar Days (PDF)
Assistant Surgeon (PDF) IV Hydration (PDF) Same Day Visits (PDF)
Bilateral Procedures (PDF) Lab Quantity Limits (PDF) - Effective 9/1/2020 Sleep Studies Place of Service (PDF) - Effective 9/1/2020
Cerumen Removal (PDF) Maximum Units (PDF) Status "B" Bundled Services (PDF)
Cosmetic Procedures (PDF) Modifier -25 clinical validation Status "P" Bundled Services (PDF) - Effective 9/1/2020
Distinct Procedural Modifiers (PDF) Modifier -59 clinical validation (PDF) Supplies Billed on Same Day as Surgery (PDF)
Duplicate Primary Code Billing (PDF) Modifier DOS Validation (PDF) Transgender Related Services (PDF)
EM Bundling Edits (PDF) Modifier to Procedure Code Validation (PDF) Unbundled Professional Services (PDF)
Global Maternity Billing (PDF) Multiple CPT Code Replacement (PDF) Unbundled Surgical Procedures (PDF)
Hospital Visit Codes Billed with Labs (PDF)
NCCI Unbundling (PDF) Unlisted Procedure Codes (PDF)
  Never Paid Events (PDF) Urine Specimen Validity Testing (PDF) - Effective 9/1/2020
  New Patient (PDF) Wheelchair Accessories (PDF) - Effective 9/1/2020
  Non-Emergent ER Services (PDF) - Effective 9/1/2020  
  Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF) - Effective 9/1/2020  
  Outpatient Consultation (PDF)  
  Physician's Consultation Services (PDF) - Effective 9/1/2020  
  Physician's Office Lab Testing (PDF)  
  Physician Visit Codes Billed with Labs (PDF)  
  Place of Service Mismatch (PDF)  
  Post-Operative Visits (PDF)  
  Pre-Operative Visits (PDF)  
  Professional Component (PDF)  
  Problem-Oriented Visits with Preventative Visits (PDF) - Effective 9/1/2020  
  Problem-Oriented Visits with Surgical Procedures (PDF) - Effective 9/1/2020  
  Pulse Oximetry (PDF)