PRC Medical Levels of Care

Brief Overview

I. Medical Priority Level I – Emergent or Acutely Urgent Care Services

1. Emergent or Acutely Urgent Care Services are 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.

II. Medical Priority Level II – Preventive Services

1. Preventive 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 Priority Level II are available at IHS direct care facilities. If no direct care capabilities are available at the IHS or Tribal direct care facility, preventative services can be purchased using PRC funds

III. Medical Priority Level III – Primary and Secondary Care Services.

1. Primary and Secondary Care Services include inpatient and outpatient care services. The inpatient and outpatient services 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 also includes services that may not be available at Tribal and IHS facilities and/or may require specialty consultation.

IV. Priority Level IV – Chronic Tertiary and Extended Care Services.

1. Chronic Tertiary and Extended Care Services are services that (1) 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 or Tribal facilities.

V. Medical Priority Level V – Excluded Services.

1. Excluded Services includes cosmetic procedures, experimental and other procedures excluded from authorization for PRC payment. The list of Medical Priority Level V-Excluded Services is based upon the Centers for Medicare and Medicaid’s (CMS) Medicare National Coverage Determinations Manual.
   1. Procedures. The Fiscal Intermediary (FI) will not pay a claim for a potentially cosmetic procedure listed in Medical Priority Level V-Excluded Services, Exceptions may be granted if one of the listed procedures, normally considered cosmetic, is necessary for proper mechanical function or psychological reasons.
   2. Experimental and other Excluded Procedures. Payment for the excluded procedures listed in Medical Priority Level V-Excluded Services will not be paid.
   3. Payment for Direct Services. Examples of direct care services that cannot be reimbursed with PRC funds are on-call hours, after hours or weekend pay, holiday coverage (e.g., for x-ray, laboratory, pharmacy).

Through Overview of PRC Medical Priority Levels

I. Medical Priority Level I – Emergent or Acutely Urgent Care Services

1. Definition. Emergent or acutely urgent care services are 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 emergent or acutely urgent care services include (random order):
   1. Emergency room care for emergent or urgent medical conditions, surgical conditions, or acute trauma.
   2. Emergency inpatient care for emergent or urgent medical conditions, surgical conditions, or acute injury.
   3. Acute and chronic renal replacement therapy.
   4. Emergency psychiatric care involving suicidal persons or those who are a serious threat to themselves or others.
   5. Services and procedures necessary for the evaluation of potentially life threatening illness or conditions.
   6. Obstetrical deliveries and acute perinatal care.
   7. Neonatal care
2. Medical Priority Level I -Diagnosis. Examples of diagnosis that usually require emergent/acutely urgent care services include but are not limited to:
   1. Musculoskeletal trauma acute
   2. Cancer Chemotherapy
   3. Cholecystitis, acute
   4. Coma
   5. Concussion
   6. Congestive heart failure, decompensated
   7. Pancreatitis
   8. Dehydration, severe
   9. Delirium tremens
   10. Diabetic ketoacidosis
   11. Drowning, near
   12. Embolism, cerebral or peripheral
   13. Encephalitis
   14. Epididymitis, acute
   15. Epiglottitis
   16. Eye disease, acute
   17. Flail chest
   18. Fractures
   19. Glomerulonephritis
   20. Gunshot wounds
   21. Head injury
   22. Heat exhaustion and prostration
   23. Hemoptysis
   24. Hemorrhage
   25. Hepatic encephalopathy
   26. Myocardial infractions
   27. Myocardial ischemia, acute
   28. Obstetrical emergencies
   29. Pelvic inflammatory disease
   30. Peritonitis
   31. Pneumonia, acute
   32. Pneumothorax
   33. Poisoning
   34. Premature infant
   35. Pulmonary embolism
   36. Pulmonary edema
   37. Puncture or stab wounds
   38. Radiation Therapy
   39. Rape, alleged, examination
   40. Renal lithisasis, acute
   41. Renal failure, acute
   42. Respiratory failure
   43. Sepsis
   44. Shock
   45. Spinal column injuries
   46. Suicide attempt
   47. Urinary retention, obstruction

II. Medical Priority Level II – Preventive Care Services

1. Definition. Preventive care services are available at most IHS facilities. Preventive care service is 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):
   1. Routine prenatal care
   2. Non-urgent preventative ambulatory care (primary prevention)
   3. Screening for known disease entities (secondary prevention)
   4. Screening Mammograms
   5. Public health intervention
2. Medical Priority Level II – Examples. Examples of procedures or services that are usually considered preventive care services include but are not limited to:
   1. Audiology screening
   2. Diabetes maintenance
   3. Hemophilus prophylaxis
   4. HIV testing
   5. Immunizations
   6. Mammography
   7. Periodic health exams of infants, children, and adults
   8. Podiatry care for diabetics
   9. Sexually transmitted diseases, testing and treatment
   10. Vision examinations
   11. Cancer screening
   12. Family planning services
   13. Hepatitis prophylaxis
   14. Hypertensive screening, diagnosis, and control
   15. Laboratory services supporting primary care evaluations
   16. Meningitis prophylaxis
   17. Pregnancy and infant care
   18. Routine PAP smears/Colposcopy
   19. Tuberculosis screening, prophylaxis, and treatment
   20. X-ray services supporting primary care evaluations

III. Medical Priority Level III – Primary and Secondary Care Services

1. Definition. Primary and Secondary Care Services include inpatient and outpatient care services. The inpatient and outpatient services 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 also includes services that may not be available at many IHS facilities and/or may require specialty consultation. Categories of services included (random order):
   1. Scheduled ambulatory services for non-emergent conditions.
   2.  Specialty consultations in surgery, medicine, obstetrics, gynecology, pediatrics, ophthalmology, ENT, orthopedics, and dermatology.
   3. Elective, routine surgeries that have a significant impact on morbidity and mortality.
   4. Diagnostic evaluations for non-acute conditions.
   5. Specialized medications not available at an IHS facility, when no suitable alternative exists.
2. Medical Priority Level III – Examples. Procedures or referrals that usually are considered Primary and Secondary Care Services included but are not limited to:
   1. Arthroscopy
   2. Bladder suspension
   3. Cardiac catheterization
   4. Cardiology referral (non-acute)
   5. Cholecystectomy
   6. CT Scan/MRI
   7. Dermatology
   8. Electroencephalogram
   9. Electronystagmogram
   10. Endocrinology
   11. Exercise stress testing
   12. Eye glasses refractions
   13. Gastroscopy
   14. Gynecology
   15. Hearing aids
   16. Hematology referral
   17. Hemorrhoidectomy
   18. Hemiorrhaphy
   19. Hysterectomy
   20. Lumbar laminectomy
   21. Nephrology/urology referral
   22. Neurology evaluations (elective)
   23. Nuclear medicine
   24. Orthotics
   25. Ophthalmology
   26. Podiatry, non-diabetic
   27. Prosthetics
   28. Psychiatric evaluations
   29. Pulmonary referral
   30. Pulmonary function testing
   31. Rheumatology
   32. Surgery referral, elective
   33. Tonsillectomy
   34. Tympanoplasty

IV. Medical Priority Level IV – Chronic Tertiary and Extended Care Services

1. Definition. Chronic Tertiary and Extended Care Services are services that (1) 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):
   1. Rehabilitation care
   2. Skilled nursing facility (Medicare defined)
   3. Highly specialized medical services/procedures
   4. Restorative orthopedic and plastic surgery
   5. Other specialized elective surgery such as obesity surgery
   6. Elective open cardiac surgery
   7. Organ transplantation (CMS approved organs only)
2. Medical Priority Level IV – Examples. Diagnosis or procedures that usually are considered Medical Priority Level IV -Chronic Tertiary and Extended Care Services included but are not limited to:
   1. Angiocardiography
   2. Coronary bypass (non-acute)
   3. Facial bone repair
   4. Immunotherapy
   5. Lithotripsy
   6. Neurosurgery
   7. Pain control programs
   8. Plasmapheresis
   9. Portable fusion pumps
   10. Radical neck surgery
   11. Rhytidectomy
   12. Valvular open-heart surgery
   13. BCG vaccine (as adjuvant therapy for cancer)
   14. Esophageal pH monitoring
   15. Gastric bypass surgery
   16. Joint replacement
   17. Mammoplasty, reconstructive
   18. Osteoplasty (osteotomy)
   19. Passive motion exercise devices
   20. Plastic surgery, reconstructive
   21. Porta-caval shunt
   22. Rhinoplasty
   23. Sympathectomy

V. Medical Priority Level V – Excluded Services

1. Definition. Excluded services are services and procedures that are considered purely cosmetic in nature, experimental or investigational, or have no proven medical benefit. The list of therapies and procedures classified as potentially cosmetic in nature, experimental, or excluded will be reviewed and updated on an annual basis.
2. Excluded Services – Categories. Categories of excluded services include:
   1. All purely cosmetic (not reconstructive) plastic surgery;
   2. Procedures defined as experimental by the Centers for Medicare and Medicaid Services;
   3. Procedures for which there is no proven medical benefit procedures listed as “Not Covered” in the CMS Medicare National Coverage Determinations Manual;
   4.  Extended care nursing homes (intermediate or custodial care); and
   5. Alternate medical practices (e.g., homeopathy, acupuncture, chemical endarterectomy, naturopathy.)
3. 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 Area CMO is required.
4. Experimental and other Excluded Services Procedures. Payment for Experimental and Other Excluded Services is not authorized, unless a formal exception is granted by the IHS CMO.
5. Medical Priority Level V – Examples.
   1. Cosmetic. Examples of cosmetic services that are considered either experimental or excluded. (Not an all-inclusive list.)
      1. Argon Laser Treatment for Congenital Hemangiomas
      2. Topical Chemotherapy (Total Face and/or Neck)
      3. Mastectomy for Gynecomastia
      4. Mastectomy, Subcutaneous with Delayed Prosthetic Implant
      5. Removal of Mammary Implant Material
      6. Reconstruction of Nipple and/or Areola
      7. Revision (Release of Scar Contracture) of Breast, following Mammoplasty
      8. Blepharoptosis Repair
      9. Tattooing
      10. Subcutaneous Injection of “Filling” Material (i.e., Collagen)
      11. Insertion of Tissue Expanders
      12. Dermabrasion
      13. Abrasion (i.e., Keratoses)
      14. Chemical Peell
      15. Salabrasion
      16. Cervicoplasty
      17. Rhytidectomy
      18. Excision Excessive Skin and Subcutaneous Tissue (Including Lipectomy)
      19. Suction Assisted Lipectomy
      20. Cryotherapy for Acne
      21. Electrolysis Epilation
      22. Mastopexy
      23. Reduction Mammoplasty
      24. Augmentation Mammoplasty
      25. Breast Reconstruction
      26. Application of Halo Type Appliance for Maxillofacial Fixation
   2. Experimental and other Excluded Services. Examples of Experimental and other Excluded Services include but are not limited to:
      1. Acupuncture
      2. Intestinal bypass surgery
      3. Intravenous histamine therapy monitoring
      4. Joint and ligament sclerosing therapy
      5. Chelation therapy for atherosclerosis
      6. Cochlear implants (under 18 years of age)
      7. Cytotoxic food tests
      8. Electrosleep therapy
      9. Food allergy testing
      10. Gastric balloon for treatment of obesity
      11. Hair transplants
      12. Heat treatment for pulmonary conditions
      13. Hemodialysis for Schizophrenia therapy
      14. Mammoplasty, cosmetic
      15. Sex-change operations
      16. Tattoo removal
      17. Tinnitus masking
      18. Plastic surgery (purely cosmetic, not reconstructive)
      19. Portable hand held x-ray instruments
      20. Pulmonary embolectomy, transvenous (catheter)
      21. Electric aversion therapy
      22. Electric nerve stimulation for motor dysfunction (not pain control)
      23. In-vitro fertilization
      24. Ambulatory blood pressure
      25. Artificial Hearts
      26. Cellular therapy
      27. Keratoplasty, refractive
      28. Colonic irrigation
      29. Dermabrasion
      30. External counterpulsation
      31. Gastric freezing
      32. Hair analysis
      33. Human tumor stem cell drug
      34. Rhinoplasty, cosmetic
      35. Sensitivity assays
      36. Scalp replantation
      37. Thermogenic therapy