| TN0705 ADEM | ||||||
|---|---|---|---|---|---|---|
| PREAUTH | CLAIMS | |||||
| MIN. CLINICAL SYMPTOMS | MIN. REQUIRED | CRITERIA | DETAILS | % breakup amount - claims | POINTS AWARDED | SPECIAL MENTION |
| VARIABLE CNS SYMPTOMS | CLINICAL PHOTO, MRI SCAN BRAIN | TOTAL BED DAYS | 20 | |||
| BEDS IN ICU | ||||||
| INVESTIGATIONS | GENERAL WORK UP | 30 | ||||
| IMAGING | mandatory | MRI BRAIN / +/- CT SCAN | ||||
| EEG | ||||||
| LP AND CSF STUDY | mandatory | |||||
| TREATMENT | STEROIDS / IMMUNOSUPPRESSION | 50 | mandatory | |||
| OTHER SUPPORTIVE CARE / MEDICATIONS | ||||||
| FOLLOW UP CARE | ||||||
| I.V.IG / PLASMAPHERESIS | ||||||