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Gather data from: CRD (Coverage Requirements of Discovery) use cases, DTR (Documentation Templates and Payer Rules), Prior Auth

Advanced COPD:

Persona: Joe Smith is a 65 yo male with end stage COPD and OSA (Obstructive Sleep Apnea)

Coverage Transition: Commercial to MA

*Diagnosis Codes: ICD-10-CM at a minimum, ok to use a SNOMED-CT translation code if available *note what is allowed in HIPPA 837 Claims requirements

Active Treatments: relevant metadata – schedule, supplier, duration of therapy, ordering provider

  • Home O2 – 2L daytime, 4L nighttime – 
  • DME: Class (from order), Make, Model, Date Provided, Date Expiring/Replacement?, GUDID?, Instructions on how to use?(probably not) * likely to have prior auth 
    • CPAP
    • Oxygen supplies (Canisters, concentrators, cannulas)
    • Nebulizer
    • Oxymeter
  • Medications: 
    • Spiriva inhaler
    • Advair inhaler
    • Duonebs inhaled via nebulizer
  • Routine PFTs (spirometry?)
  • Home monitoring?
  • Specialty care: 
    • Pulmonary Consult

Prior authorizations: specific to insurer, patient and plan-- there is not a category-- would be an optional component for which the payer would want the information about what was provided and the determination


Gather data from: Wound care implementation guide/data set, ADA?

Persona: 82 yo F Glenda Goodwitch with insulin-dependent DM for 19 years, has multiple complications including chronic wounds and retinopathy

Coverage transition: MA to MA

  • Consider impact of Medicare supplemental plan?

Diagnosis Codes: SNOMED-CT 237599002 | Insulin treated type 2 diabetes mellitus (disorder or ICD-10-CM E11.65 “Type 2 diabetes mellitus with other specified complications.”

Goal: Hba1c <7.5

Provider: Dokter Bronsig

Active Treatments: relevant metadata – schedule, supplier, duration of therapy, ordering provider

  • Non-DME Supplies: 
    • Diabetes: 
      • Glucose testing strips
      • Lancets
      • Syringes and needles
    • Wound care:
      • Bandages
      • Wet dressings
  • DME:
    • Glucometer–investigate coverage patterns for glucometers
  • Medications:
    • Humalog SSI
    • Lantus BID
    • Exenatide BID
    • Antibiotics*-- fixed duration 
    • Bacitracin
  • Diabetes Care Management Program – from payer, provider, outside resource? would all data be similarly available?
  • Specialty Care: Ophthalmology-- may require procedures to treat, unclear if these would be scheduled
    • Could consider CKD/renal as part of this use case
  • Ancillary Care: Wound care, Home RN – consider how to categorize ancillary care vs home services

Prior authorizations: 

  • Exenatide-- 06/11/2019-06/11/2020

Liver Transplant:

Persona: 55 yo with liver transplant for NASH/ETOH, comorbid depression

Coverage Transition: Commercial to Commercial

Diagnosis Codes: TBD

Active Treatments:

  • Medications:
    • Immunosuppression
  • Counseling/mental health services
  • Substance abuse follow up
  • Specialty Care: Transplant Surgery
  • Transplant Coordinator and Care Management

Past treatments? – Transplant surgery, pre-transplant therapy?

Prior authorizations

Notes from discussion: 

  • What is the role of supplemental coverage? Would they have clinical data relevant to these use cases or the exchange of data?
  • Past Medical History: what if any PMH should be transmitted? How do we determine what is relevant and what is not
    • PMH will be transmitted in as much as it is relevant to current conditions/treatments

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