Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
1 BurnsAbove 60% Mixed Burns ( With
Surgeries) (S13N1.7)
Clinical photo of affected part diagramatic
distribution of burns mandatory(Rule of 9)Clinical photo of affected part
2 BurnsUp To -60% Mixed Burns( With
Surgeries) (S13N1.6)
Clinical photo of affected part diagramatic
distribution of burns mandatory(Rule of 9)Clinical photo of affected part
3 BurnsUp to -40% With scalds (
conservative) (S13N1.1)
Clinical photo of affected part diagramatic
distribution of burns mandatory(Rule of 9)
Note that lessthan 30 % burns are covered by the
scheme
Clinical photo of affected part
4 Burns Upto-40% Mixed Burns( With surgeries) (S13N1.2)
Clinical photo of affected part diagramatic
distribution of burns mandatory(Rule of 9)
Note that lessthan 30 % burns are covered by the
scheme
Clinical photo of affected part
5 Burns Upto-50% with scalds(Conservative) (S13N1.3)Clinical photo of affected part diagramatic
distribution of burns mandatory(Rule of 9)Clinical photo of affected part
6 Burns Up to -50% Mixed Burns( With surgeries) (S13N1.4Clinical photo of affected part diagramatic
distribution of burns mandatory(Rule of 9)Clinical photo of affected part
7 BurnsUp to -60% With scalds (
conservative) (S13N1.5)
Clinical photo of affected part diagramatic
distribution of burns mandatory(Rule of 9)Clinical photo of affected part
8 Burns
Post Burn contracture surgeries for functional improvement (Package
including splints pressure garments and Physiotherapy) - Mild
(S13N2.1)
Clinical photo of affected part Clinical photo of affected part
9 Burns
Post Burn contracture surgeries for functional improvement (Package
including splints pressure garments and Physiotherapy) - Moderate
(S13N2.2)
Clinical photo of affected part Clinical photo of affected part
10 Burns
Post Burn contracture surgeries for functional improvement (Package
including splints pressure garments and Physiotherapy) - Severe
(S13N2.3)
Clinical photo of affected part Clinical photo of affected part
11
Cardiac and
Cardiothoracic
Surgeries
Dissecting Aneurysms
(S7F11.6)CT Angio/2D Echo Post procedure Doppler, operation notes
12
Cardiac and
Cardiothoracic
Surgeries
Intrathoracic Aneurysm- Aneurysm Requiring Bypass (With Graft)
(S7F11.5)CT-ANGIO/ Coronary Angio Post procedure Doppler, operation notes
13
Cardiac and
Cardiothoracic
Surgeries
Intrathoracic Aneurysm- Aneurysm Not Requiring Bypass (With Graft)
(S7F11.4)CT-ANGIO Post procedure Doppler, operation notes
14
Cardiac and
Cardiothoracic
Surgeries
Aneurysm Resection & Grafting(S7F11.3) 2D ECHO, /CT- Angio Post procedure Doppler, operation notes
15
Cardiac and
Cardiothoracic
Surgeries
Coarctation Of Aorta Repair
Without Graft (S7F11.2)
2D ECHO /CT- Angio
AORTOGRAM IS NECESSARY.Post procedure Doppler, operation notes
16
Cardiac and
Cardiothoracic
Surgeries
Coarctation Of Aorta Repair
With Graft (S7F11.1)
2D ECHO /CT- Angio
AORTOGRAM IS NECESSARY.Post procedure Doppler, operation notes
17
Cardiac and
Cardiothoracic
Surgeries
Surgery-PDA (S7F13.16) 2D Echo 2D Echo, Operation notes
18
Cardiac and
Cardiothoracic
Surgeries
Intracardiac Repair Of Vsd
(S7F13.15)2D Echo 2D Echo, Operation notes
19
Cardiac and
Cardiothoracic
Surgeries
Surgery For Intracardiac
Tumours (S7F13.12)2D ECHO
2D ECHO/ Histopath , Post
surgery PHOTOGRAPH, Operation notes
SCAR PHOTO IS MANDATORY(female patients
may be made an exception)
20
Cardiac and
Cardiothoracic
Surgeries
Carotid Embolectomy
(S7F13.11)CT- Angio Doppler, Operation notes
21
Cardiac and
Cardiothoracic
Surgeries
Femoro-Femoral Bypass
Without Graft (S7F13.8)CT- Angio/ MRI Angio Doppler, Operation notes
22
Cardiac and
Cardiothoracic
Surgeries
Femoro-Femoral Bypass With
Graft (S7F13.7)CT- Angio/ MRI Angio Doppler, Operation notes
23
Cardiac and
Cardiothoracic
Surgeries
Femoroileal Bypass Without
Graft (S7F13.6)CT- Angio/ MRI Angio Doppler, Operation notes
24
Cardiac and
Cardiothoracic
Surgeries
Femoroileal Bypass With Graft
(S7F13.5)CT- Angio/ MRI Angio Doppler, Operation notes
25
Cardiac and
Cardiothoracic
Surgeries
Femoro Popliteal Bypass
Without Graft (S7F13.4)CT- Angio/ MRI Angio Doppler, Operation notes
26
Cardiac and
Cardiothoracic
Surgeries
Femoro Popliteal Bypass With
Graft (S7F13.3)CT- Angio/ MRI Angio Doppler, Operation notes
27
Cardiac and
Cardiothoracic
Surgeries
Total Correction Of Tetralogy
Of Fallots (S7F14.3)2D Echo 2D Echo, Operation notes
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
28
Cardiac and
Cardiothoracic
Surgeries
Systemic Pulmonary Shunts
Without Graft (S7F14.2)2D Echo 2D Echo, Operation notes
29
Cardiac and
Cardiothoracic
Surgeries
Systemic Pulmonary Shunts
With Graft (S7F14.1)2D ECHO 2D Echo, Operation notes
30
Cardiac and
Cardiothoracic
Surgeries
Mitral Valvotomy (Open) (S7F17.4) 2D Echo
2D Echo, Operation notes SCAR PHOTO IS
MANDATORY (female patients may be made
an exception)
31
Cardiac and
Cardiothoracic
Surgeries
Closed Mitral Valvotomy
(S7F17.3)2D Echo
2D Echo, Operation notes SCAR PHOTO IS
MANDATORY (female patients may be made
an exception)
32
Cardiac and
Cardiothoracic
Surgeries
Open Pulmonary Valvotomy
(S7F17.2)2D Echo
2D Echo, Operation notes SCAR PHOTO IS
MANDATORY (female patients may be made
an exception)
33
Cardiac and
Cardiothoracic
Surgeries
Sol Mediastinum (S7F18.5) CT-CHEST /X- RAY
Xray, Histopathology report, Operation notes
CLINICAL PHOTO DURING CLAIMS IS
MANDATORY (female patients may be made
an exception)
34
Cardiac and
Cardiothoracic
Surgeries
Lung Cyst (S7F18.4) CT-CHEST /X- RAY
Xray, Histopathology report, Operation notes
CLINICAL PHOTO DURING CLAIMS IS
MANDATORY (female patients may be made
an exception)
35
Cardiac and
Cardiothoracic
Surgeries
Lobectomy (S7F18.2) CT-CHEST /X- RAY
Xray, Histopathology report, Operation notes
CT/MRI & CLINICAL PHOTO DURING CLAIMS IS
MANDATORY (female patients may be made
an exception)
36
Cardiac and
Cardiothoracic
Surgeries
Pneumonectomy (S7F18.1) CT-CHEST /X- RAY
Xray, Histopathology report, Operation notes
CT/MRI & CLINICAL PHOTO DURING CLAIMS IS
MANDATORY (female patients may be made
an exception)
37
Cardiac and
Cardiothoracic
Surgeries
Intracardiac Repair Of Asd
(S7F19.1)2D Echo
2D Echo, Operation notes CLINICAL PHOTO
DURING CLAIMS IS MANDATORY (female
patients may be made an exception)
38
Cardiac and
Cardiothoracic
Surgeries
Diaphragmatic Hernia
(S7F20.2)X-ray ,USG
Post procedure clinical photo, Xray, Operation
Notes CLINICAL PHOTO DURING CLAIMS IS
MANDATORY (female patients may be made
an exception)
39
Cardiac and
Cardiothoracic
Surgeries
Renal Angioplasty (S7F5.1) Angiography
Angioplasty Video, Stent stickers Claims
approval subject to stent visiblity and
restoration of arterial lumen in angioplasty
video.
40
Cardiac and
Cardiothoracic
Surgeries
Mitral Valve Replacement
(With Valve) (S7F6.4)2D Echo
Post procedure clinical photo, 2D Echo/ Xray
chest, operation notes sticker mandatory for
claim (female patients may be made an
exception for scar photo)
41
Cardiac and
Cardiothoracic
Surgeries
CABG With Aneurysmal Repair
(S7F6.3)Angiography
Post surgery PHOTOGRAPH / DOPPLER,
operation notes (female patients may be made
an exception for scar photo)
42
Cardiac and
Cardiothoracic
Surgeries
CABG Off Pump Without Iabp
(S7F6.2)Coronary Angiography report & Video, 2D Echo
X-Ray chest, Operation notes Post surgery photo
(female patients may be made an exception for
scar photo)
43
Cardiac and
Cardiothoracic
Surgeries
CABG On Pump Without Iabp
(S7F6.1)Coronary Angiography report & Video, 2D Echo
X-Ray chest, Operation notes Post surgery photo
SCAR PHOTO IS MANDATORY DURING CLAIMS
(female patients may be made an exception for
scar photo)
44
Cardiac and
Cardiothoracic
Surgeries
Coronary Bypass Surgery Off
Pump With Iabp (S7F6.6)Coronary Angiography report & Video, 2D Echo
X-Ray chest, Operation notes Post surgery photo
IN 2D ECHO EF SHOULD BE LESS THAN 40% IS
MANDATORY FOR PREAUTH IABP STICKER FOR
CLAIMS REQUIRED (female patients may be
made an exception for scar photo)
45
Cardiac and
Cardiothoracic
Surgeries
Coronary Bypass Surgery On
Pump With Iabp(S7F6.5)Coronary Angiography report & Video, 2D Echo
X-Ray chest, Operation notes Post surgery photo
IN 2D ECHO EF SHOULD BE LESS THAN 40% IS
MANDATORY FOR PREAUTH. IABP STICKER FOR
CLAIMS REQUIRED (female patients may be
made an exception for scar photo)
46
Cardiac and
Cardiothoracic
Surgeries
Double Valve Replacement
(With Valve) (S7F9.3)2D ECHO
2D Echo/ Xray, Post surgery photo, bar code
sticker, Operation notes (female patients may
be made an exception for scar photo)
47
Cardiac and
Cardiothoracic
Surgeries
Tricuspid Valve Replacement
(S7F9.2)2D ECHO
2D Echo/ Xray, Post surgery photo, bar code
sticker, Operation notes (female patients may
be made an exception for scar photo)
48
Cardiac and
Cardiothoracic
Surgeries
Aortic Valve Replacement
(With Valve) (S7F9.1)2D ECHO
2D Echo/ Xray, Post surgery photo, bar code
sticker, Operation notes (female patients may
be made an exception for scar photo)
49
Cardiac and
Cardiothoracic
Surgeries
Carotid Artery Bypass With
Synthetic Graft (S7F9.17)
CT angio/ MRI-angio/ Color
Doppler/ ANGIOGRAM
COLOR DOPPLER, Operation Notes, Barcode
Sticker
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
50
Cardiac and
Cardiothoracic
Surgeries
Brachioradial Bypass With
Synthetic Graft (S7F9.15)
CT angio/ MRI-angio/ Color
Doppler/ ANGIOGRAM
COLOR DOPPLER, Operation Notes, Barcode
Sticker
51
Cardiac and
Cardiothoracic
Surgeries
Femorodistal Bypass With
Synthetic Graft (S7F9.13)
CT angio/ MRI-angio/ Color
Doppler/ ANGIOGRAM
COLOR DOPPLER, Operation Notes, Barcode
Sticker
52
Cardiac and
Cardiothoracic
Surgeries
Femorodistal Bypass With Vein
Graft (S7F9.12)
CT angio/ MRI-angio/ Color
Doppler/ ANGIOGRAMCOLOR DOPPLER, Operation Notes
53
Cardiac and
Cardiothoracic
Surgeries
Axillo Bifemoral Bypass With
Synthetic Graft (S7F9.11)
CT angio/ MRI-angio/ Color
Doppler/ ANGIOGRAM
COLOR DOPPLER, Operation Notes, Barcode
Sticker
54
Cardiac and
Cardiothoracic
Surgeries
Aorto Bi-illac - Bifemoral Bypass With Synthetic Graft (S7F9.10)CT angio/ MRI-angio/ Color
Doppler/ ANGIOGRAM
COLOR DOPPLER, Operation Notes, Barcode
Sticker
55
Cardiac and
Cardiothoracic
Surgeries
Medium Size Arterial Aneurysms With Synthetic Graft (S7F9.9)CT angio/ MRI-angio/ Color
Doppler/ ANGIOGRAM
COLOR DOPPLER, Operation Notes, Barcode
Sticker
56
Cardiac and
Cardiothoracic
Surgeries
Medium Size Arterial
Aneurysms - Repair (S7F9.8)
CT angio/ MRI-angio/ Color
Doppler/ ANGIOGRAMCOLOR DOPPLER, Operation notes
57
Cardiac and
Cardiothoracic
Surgeries
Small Arterial Aneurysms - Repair (S7F9.7)CT angio/ MRI-angio/ Color
Doppler/ ANGIOGRAMCOLOR DOPPLER, Operation notes
58
Cardiac and
Cardiothoracic
Surgeries
D V T - Ivc Filter (S7F9.5) COLOR DOPPLER Post procedure Angio
59
Cardiac and
Cardiothoracic
Surgeries
A V Fistula At Elbow (S7F9.21) COLOR DOPPLER Clinical Photo/COLOR DOPPLER
60
Cardiac and
Cardiothoracic
Surgeries
A V Fistula At Wrist (S7F9.20) COLOR DOPPLER Clinical Photo/COLOR DOPPLER
61
Cardiac and
Cardiothoracic
Surgeries
Arterial Embolectomy
(S7F9.19)ANGIOGRAM/ COLOR DOPPLER
If peripheral embolectomy-
COLOUR DOPPLER AND PROCEDURE NOTES
ONLY FOR CLAIMS.If abdominal artery
embolectomy then CT angiogram required
62
Cardiac and
Cardiothoracic
Surgeries
Excision Of Av Malformation
Small (S7F9.18)
MRI ANGIOGRAM/SPIRAL CT
/ANGIOGRAMCOLOR DOPPLER, Operation notes
63
Cardiac and
Cardiothoracic
Surgeries
Excision Of Av Malformation
Large(S7F9.22)
MRI ANGIOGRAM/SPIRAL CT
/ANGIOGRAMCOLOR DOPPLER, Operation notes
64
Cardiac and
Cardiothoracic
Surgeries
Peripheral Embolectomy
Without Graft (S7F9.23)ANGIOGRAM/ COLOR DOPPLER COLOR DOPPLER, Operation notes
65
Cardiac and
Cardiothoracic
Surgeries
Vascular tumours (S7F9.6) Angiogram / Spiral CT COLOR DOPPLER / Scar Photo, Operation notes
66
Cardiac and
Cardiothoracic
Surgeries
Axillo brachial bypass using with synthetic graft (S7F9.14) Angiogram / Spiral CT COLOR DOPPLER / Scar Photo, Operation notes
67
Cardiac and
Cardiothoracic
Surgeries
Carotid Body tumours Excision
(S7F9.16)Angiogram / Spiral CT COLOR DOPPLER / Scar Photo, Operation notes
68
Cardiac and
Cardiothoracic
Surgeries
Surgery without CPB (S7F12.1) 2D Echo / Xray chest/ CT 2D Echo/Scar photo
69
Cardiac and
Cardiothoracic
Surgeries
Surgery with CPB (S7F12.2) 2D Echo / Xray chest/ CT 2D Echo/Scar photo
70
Cardiac and
Cardiothoracic
Surgeries
Pericardiostomy (S7F9.4) 2D Echo / CT 2D Echo/Scar photo
71
Cardiac and
Cardiothoracic
Surgeries
Percardectomy (S7F10.1) 2D Echo / CT 2D Echo/Scar photo
72
Cardiac and
Cardiothoracic
Surgeries
Pericardiocentesis (S7F10.2) 2D Echo / CT 2D Echo/Scar photo
73
Cardiac and
Cardiothoracic
Surgeries
Annulus aortic ectasia with valved conduits (S7F11.7) Angio / 2Decho/ CT 2D Echo/Scar photo
74
Cardiac and
Cardiothoracic
Surgeries
Aorto-aorto bypass with graft
(S7F13.1)Angio /CT angio/ MR angio Doppler, Operation notes/ Scar Photo
75
Cardiac and
Cardiothoracic
Surgeries
Aorto-aorto bypass without graft (S7F13.2) Angio /CT angio/ MR angio Doppler, Operation notes/ Scar Photo
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
76
Cardiac and
Cardiothoracic
Surgeries
TGA Arterial switch (S7F13.9) 2D Echo / Angio 2D Echo/Scar Photo
77
Cardiac and
Cardiothoracic
Surgeries
TGA Sennings Procedure
(S7F13.10)2D Echo / Angio 2D Echo/Scar Photo
78
Cardiac and
Cardiothoracic
Surgeries
Ruptured sinus of valsalva correction (S7F13.13) CAG / 2D Echo 2D Echo/Scar Photo
79
Cardiac and
Cardiothoracic
Surgeries
TAPVC correction (S7F13.14) 2D Echo/ CT 2D Echo/Scar Photo
80
Cardiac and
Cardiothoracic
Surgeries
Ross procedure Intracardiac repair of complex congenital heart with
special conduits (S7F16.1)2D Echo 2D Echo/Scar Photo
81
Cardiac and
Cardiothoracic
Surgeries
Ross procedure Intracardiac repair of complex congenital heart without
special conduits (S7F16.2)2D Echo 2D Echo/Scar Photo
82
Cardiac and
Cardiothoracic
Surgeries
Valve repair with Prosthetic ring (S7F13.17) 2D Echo 2D Echo/Scar Photo
83
Cardiac and
Cardiothoracic
Surgeries
Valve repair without Prosthetic ring (S7F17.1) 2D Echo 2D Echo/Scar Photo
84
Cardiac and
Cardiothoracic
Surgeries
Decortication (S7F18.3) CT Chest Clinical Photo / Xray
85
Cardiac and
Cardiothoracic
Surgeries
Thoracoplasty (S7F19.2) CT Chest Clinical Photo / Xray
86
Cardiac and
Cardiothoracic
Surgeries
Myoplasty (S7F19.3) CT Chest Clinical Photo / Xray
87
Cardiac and
Cardiothoracic
Surgeries
Transpleural BPF Closure
(S7F19.4)CT Chest Clinical Photo / Xray
88
Cardiac and
Cardiothoracic
Surgeries
Diaphragmatic Eventeration
(S7F20.1)Barium studies / CT scan Clinical Photo / Xray
89
Cardiac and
Cardiothoracic
Surgeries
Oesophageal diverticula/ Achlasia cardia (S7F20.3) Barium studies / CT scan USG /Scar Photo
90
Cardiac and
Cardiothoracic
Surgeries
Thoracotomy, Thoraco abdominal approach (S7F21.1) CT Scan Clinical Photo with scar
91
Cardiac and
Cardiothoracic
Surgeries
Bronchial Foreign Body Removal With Scope(S7F22.1) Broncoscopy / CT scan Post Procedure Endoscopic Picture
92
Cardiac and
Cardiothoracic
Surgeries
Bronchial Injuries Due To Foreign Body Repair Surgery (S7F22.2) Broncoscopy / CT scan Post Procedure Endoscopic Picture
93
Cardiac and
Cardiothoracic
Surgeries
Gastro study followed by Thoracotomy and repairs for Oesophageal
injury for corrosive injuries/FB (S7F23.1)Gastroscopy Post procedure endoscopic picture
94
Cardiac and
Cardiothoracic
Surgeries
Surgery without graft for arterial injuries, venous injuries (S7F24.1) Angiogram /Doppler/ CT angio Clinical Photo with scar
95
Cardiac and
Cardiothoracic
Surgeries
Vascular injury in upper limbs- Axillary, Brachial, Radial and Ulnar repair
with vein graft (S7F24.2)Angiogram /Doppler/ CT angio Doppler / Scar Photo
96
Cardiac and
Cardiothoracic
Surgeries
Major Vascular Injury in Lower
Limbs repair (S7F24.3)Angiogram /Doppler/ CT angio Doppler / Scar Photo
97
Cardiac and
Cardiothoracic
Surgeries
Minor Vascular Injury repair- tibial vessels in leg (S7F24.4) Angiogram /Doppler/ CT angio Doppler / Scar Photo
98
Cardiac and
Cardiothoracic
Surgeries
Minor Vascular Injury repair- Vessels in foot (S7F24.5) Angiogram /Doppler/ CT angio Doppler / Scar Photo
99
Cardiac and
Cardiothoracic
Surgeries
Surgery with Vien Graft
(S7F24.6)Angiogram /Doppler/ CT angio Doppler / Scar Photo
100
Cardiac and
Cardiothoracic
Surgeries
Vascular Injury Repair With
Prosthetic Graft (S7F24.7)Angiogram /Doppler/ CT angio Doppler / Scar Photo
101
Cardiac and
Cardiothoracic
Surgeries
Neck Vascular Injury- Carotid
Vessels (S7F24.8)Angiogram /Doppler/ CT angio Doppler / Scar Photo
102
Cardiac and
Cardiothoracic
Surgeries
Abdominal Vascular Injuries- Aorta, Iliac arteries, IVC, Iliac Veins
(S7F24.9)Angiogram /Doppler/ CT angio Doppler / Scar Photo
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
103
Cardiac and
Cardiothoracic
Surgeries
Thoracic Vascular Injuries
(S7F24.10)Angiogram /Doppler/ CT angio Doppler / Scar Photo
104 CardiologyAngioplasty With Stent
(M7F1.3)Coronary Angiography report & Video
Angioplasty Video, Stent stickers Claims
approval subject to stent visiblity and
restoration of arterial lumen in angioplasty
video.
105 Cardiology Ptca Additional Stent (M7F1.2) Coronary Angiography report & Video
Angioplasty Video, Stent stickers Claims
approval subject to stent visiblity and
restoration of arterial lumen in angioplasty
video.
106 CardiologyCoronary Ballon Angioplasty
(M7F1.1)Coronary Angiography report & Video
Angioplasty Video, Stent stickers Claims
approval subject to stent visiblity and
restoration of arterial lumen in angioplasty
video.
107 CardiologyTemporary Pacemaker
Implantation (M7F3.2)
ECG with date & name of patient
(preferably printed)Post procedure clinical photo, ECG
108 CardiologyPermanent Pacemaker
Implantation (M7F3.1)
ECG with date & name of patient
(preferably printed)
Post procedure clinical photo,ECG, X-Ray chest/
Fluoroscopic Image
109 CardiologyPericardial Effusion
Tamponade (M7T1.10)2D ECHO 2D Echo,Lab Investigations Of Pericardial Fluid
110 Cardiology Simple Arrhythmias (M7T1.9)ECG with date & name of patient
(preferably printed)
Clinical notes, ECG Focus ABLATION IF DONE,
THEN PROCEDURE NOTES ARE mandatory for
claims
111 CardiologyComplex Arrhythmias
(M7T1.8)
ECG with date & name of patient
(preferably printed)
Clinical notes, ECG Cartoguided ABLATION IF
DONE, THEN PROCEDURE NOTES ARE
Mandatory for claims
112 Cardiology Pulmonary Embolism (M7T1.7) Doppler, CT Pul angio/ angio,ECG , Clinical notes, CT Pulm Angio is
mandatory at the time of claim.
113 CardiologyInfective Endocarditis
(M7T1.6)ECG, 2D Echo, CBC, ESR
Post procedure evidence of clinical
improvement & ECG, Lab investigations, Blood
culture (can be negative)
114 CardiologyRefractory Cardiac Failure
(M7T1.5)
ECG, 2D Echo, CXR ,CPK & Trop T required at the
time preauth, Patient has to be certified by
cardiologist/Physician for the same at the time of
preauth.
ECG, 2D Echo,Evidence of treatment resulting in
refractory cardiac failure,
115 CardiologyAcute Mi Requiring Iabp Pump
(M7T1.4)TROPONIN, ECG, CPKMB, 2D Echo, Clinical notes
Lab investigations, Clinical notes IABP sticker
mandatory at the time of claim.
116 CardiologyAcute Mi With Cardiogenic
Shock (M7T1.3)
ECG with date & name, Cardiac
Enzymes, Clinical NotesLab investigations, Clinical notes
117 CardiologyThrombolytic thearpy for
Acute Mi (M7T1.1)Serial ECG with date & name, Cardiac Enzymes Lab investigations, Clinical notes
118 CardiologyCoil Closure Multiple Coils
(S7F1.8)2D ECHO
Fluoroscopy Image/ Video fluroscopy videos, ot
notes, stickers as and where applicable
119 CardiologyCoil Closure Single Coil
(S7F1.7)2D ECHO
Fluoroscopy Image/ Video fluroscopy videos, ot
notes, stickers as and where applicable
120 Cardiology PDA Device Closure (S7F1.6) 2D ECHOFluoroscopy Image/ Video fluroscopy videos, ot
notes, stickers as and where applicable
121 Cardiology VSD Device Closure (S7F1.4) 2D ECHOFluoroscopy Image/ Video fluroscopy videos, ot
notes, stickers as and where applicable
122 Cardiology ASD Device Closure (S7F1.3) 2D ECHOFluoroscopy Image/ Video fluroscopy videos, ot
notes, stickers as and where applicable
123 Cardiology PDA Stenting (S7F1.5) 2D ECHOFluoroscopy Image/ Video fluroscopy videos, ot
notes, stickers as and where applicable
124 CardiologyBalloon Atrial Septostomy
(S7F2.2)2D ECHO
Fluoroscopy Image/ Video fluroscopy videos, ot
notes, stickers as and where applicable
125 Cardiology Balloon Valvotomy (S7F2.1) 2D EchoFluoroscopy Image/ Video fluroscopy videos, ot
notes, stickers as and where applicable
126 CardiologyCoarctation Of Aorta Repair
Without Stent (S7F4.2)
2D ECHO /CT angio/ angio,
aortogram at the time of preauthFluoroscopy Image/ Video
127 CardiologyCoarctation Of Aorta Repair
With Stent (S7F4.1)
2D ECHO /CT angio/ angio,
aortogram at the time of preauth
Fluoroscopy Image/ Video, sticker mandatory
for claim, Claims approval subject to stent
visiblity and restoration of arterial
lumen in angioplasty video.
128 Cardiology Peripheral Angioplasty(S7F5.2) Angiography
Angioplasty Video, Stent stickers, Claims
approval subject to stent visiblity and
restoration of arterial lumen in angioplasty
video.
129 Cardiology Vertebral Angioplasty (S7F5.3) Angiography
Angioplasty Video, Stent stickers,
Claims approval subject to stent visiblity and
restoration of arterial lumen in angioplasty
video.
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
130 Critical Care Septic Shock(Icu Management) With Ventilatory Assistance (M3Q1.8)
Machine generated ABG, RFT, USG, Urine R/M,
Clinical photograph, Xray chest, CBC.Justification
from treating Physician for necessity of
ventilatory support if SpO2 is
>80%, esp. of no evidence of alkalosis/acidosis
ABG, Lab Investigations, Post treatment
evidence of clinical improvement, report of
Blood culture/ Urine culture If blood culture
report is negative then other markers of sepsis
like Urine culture , sputam culture, C3
marker,csf ananlysis to be given to confirm the
dignosis septic shock
131 Critical CareOp Poisoning Requiring Ventilatory Assistance Clinical Photo - 1 Week
Stay (M3Q1.7)
Clinical photo on ventilator, RFT, Machine
generated ABG, Sr cholinesterase
ABG, Lab Investigations, Post treatment
evidence of clinical improvement
132 Critical CareARDS Plus DIC (Blood & Blood Products) With Ventilatory Care
(M3Q1.6)
Chest X-Ray, Machine generated ABG, Clinical
photo with ventilator support, CBC, DIC profile
ABG, Lab Investigations, Post treatment
evidence of clinical improvement
133 Critical CareARDS With Multi Organ Failure With Ventilatory Care 14 Days Stay
(M3Q1.5)
Chest X-Ray/ HRCT Chest, Machine generated
ABG, Clinical photo, RFT, LFT, CBC, Sr Electrolites
For ARDS packages Ventilator with NIV Mask /
invasive ventilator should be discretion of
treating physician
ABG, Lab Investigations(CBC, LFT, RFT), Post
treatment evidence of clinical improvement.
Justification from treating dr for standalone
NIV treatment(if given) in ARDS
134 Critical CareARDS With Ventilatory Care 14
Days Stay(M3Q1.4)
Chest X-Ray/ HRCT Chest, Machine generated
ABG, Clinical photo with Ventilatory support,
For ARDS packages Ventilator with NIV Mask /
invasive ventilator should be discretion of
treating physician, CPAP, BiPAP is not accepted
ABG, Lab Investigations, Post treatment
evidence of clinical improvement
135 Critical CareAcute Bronchitis And Pneumonia With Respiratory Failure, Ventilator
10 Days Stay (M3Q1.3)
Chest X-Ray/ HRCT Chest, Machine generated
ABG, Clinical photo with ventilatory support,
ABG, Lab Investigations, Post treatment
evidence of clinical improvement
136 Critical Care
COPD - Respiratory Failure
(Infective Exacerbation)14
Days Stay (M3Q1.2)
Chest X-Ray/ HRCT Chest/ Spirometry, Clinical
photo, , Machine generated ABG
ABG, Lab Investigations, X-
ray, Post treatment evidence of clinical
improvement
137 Critical Care
Acute Severe Asthma With
Acute Respiratory Failure 10
Days Stay(M3Q1.1)
Machine generated ABG, Clinical Photo with
ventilator support, Chest X-Ray
ABG, Lab Investigations, X- ray, Post treatment
evidence of clinical improvement
138 DermatologyToxic Epidermal necrolysis
(M11T5. 1)
Urine R/M, CBC, LFT, RFT, Skin
SwabClinical notes, CBC, LFT, RFT, Skin Biopsy
139 DermatologyStevens Johnson Syndrome
(M11T5. 2)
Urine R/M, CBC, LFT, RFT, Skin
SwabClinical notes, CBC, LFT, RFT, Skin Biopsy
140 Dermatology Pemphigus/ Pemphigoid Tzanck clinical protocol (M11T5. 3) Tzanck Smear, Serum DSG 1& 3 Clinical notes, Skin Biopsy
141 EndocrinologyPyelonephritis 10 days stay
(M13U2.4)Urine R/M, USG
Post procedure Evidence of clinical imrovement
, LAB INVESTIGATIONS, Urine C/S
142 Endocrinology Lower Respiratory tract infection (M13U1.1)10 Days Stay CXR, Sputum gram stain Post Procedure Evidence Of Clinical
Imrovement , Lab Investigations
143 Endocrinology Fungal sinusitis PNS 10 Days (M13U1. 2)
CT PNS, Direct microscopy report
to confirm Fungal hyphae is mandatory during
preauth
Post Procedure Evidence Of Clinical
Imrovement , Lab Investigations
144 Endocrinology Cholecystitis Abd 10 Days Stay (M13U1.3) USG /CT Abd, LFT Post Procedure Evidence Of Clinical
Imrovement , Lab Investigations
145 EndocrinologyCavernous sinus thrombosis
10 Days Stay (M13U1.4)MRI, Venogram
Post Procedure Evidence Of Clinical
Imrovement , Lab Investigations
146 EndocrinologyRhinocerebral mucormycosis
10 Days Stay(M13U1.5)
CT-Scan, (Brain PNS Chest) when necessary,
Direct microscopy report for Fungal hyphae is
mandatory during preauth.
Post Procedure Evidence Of Clinical
Imrovement , Lab Investigations
147 Endocrinology Hypopitutarism 1 Week Stay (M13U1.6)
T3 T4 TSH, basal cortisol post-ACTH cortisol, GH
stimulation test, FSH, LH, Testosterone or Estradiol
GH stimulation test 1 yr. needed MRI pic visual
field water deprivation test 1 yr. needed
Post Procedure Evidence Of Clinical, Lab
Investigations, Injection Vial With Patient Name
On It And Bills Of The Injection Are Mandatory
For Claims
148 EndocrinologyPituitary – Acromegaly 1 Week Stay
(M13U2.1)
Post glucose GH assay, prolactin, t3 t4 TSH, Basal
cortisol cost ACTH, FSH / LH, testosterone / estriol,
water deprivation test (if needed)
Post Procedure Evidence Of Clinical, Lab
Investigations
149 EndocrinologyCUSHINGs Syndrome
(M13U2.2)
Cortisol assay after dexamethasone, ACTH assay,
DHEAS, MRI pituitary CT Abd, Dexa of Hip spine
Post procedure Evidence of clinical, LAB
INVESTIGATIONS
150 EndocrinologyDelayed Puberty Hypogonadism (ex.Turners synd, Kleinfelter synd)
(M13U2.3)
FSH, LH, testosterone, estradiol, USG pelvis,
karyotyping, T4 TSH, Xray bone age, X-ray skull,
MRI brain DEXA, 2D echo
Post procedure Evidence of clinical, LAB
INVESTIGATIONS
151 ENT SurgeryAdenoidectomy - Gromet
Insertion (S2B2.6)X-RAY NASOPHARYNX Post procedure clinical photograph
152 ENT SurgeryParapharyngeal Tumour
Excision (S2B2.5)CT- SCAN /MRI SCAN, FNAC BIOPSY,Post procedure clinical photograph
153 ENT Surgery Excision Of Tumours In Pharynx (S2B2.4) FNAC/biopsy, CT Scan Histopath report
154 ENT SurgeryExcision Of Benign Tumour
Nose (S2B3.5)CT PNS, DNE Post procedure clinical photograph
155 ENT Surgery Tympanoplasty (S2B3.3) AudiometryIntra OP Photo Post OP Pure Tone Audiometry
is required
156 ENT Surgery Mastoidectomy (S2B3.2) X-Ray/CT Temporal bone Post procedure clinical photograph
157 ENT SurgeryEndoscopic Sinus Surgery
(S2B3.1)CT PNS,DNE PHOTO GRAPH ENDOSCOPIC PHOTOGRAPH/ Sketch
158 ENT Surgery Bronchoscopic Foreign Body Removal (S2B4.1) RELEVANT X-RAYPost procedure clinical photograph, Post Op
Xray
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
159 ENT SurgeryBehind The Ear Analogue
Hearing Aid (S2P1.1)machine generated Audiometry
Clinical photo(10% of the
cases will be reinvestigated
in Government hospitals for Audiometry after
discharge)
160 ENT Surgery labyrinthectomy (S2B1.1) CT Scan PTI, IA Clinical photo
161 ENT SurgeryFacial nerve Decompression
(S2B1.2)CT Scan Clinical photo
162 ENT SurgeryTemporal Bone Excision
(S2B1.2)CT scan/ MRI Clinical photo
163 ENT SurgeryMicrolaryngeal Surgery
(S2B2.1)Nasal Endoscopy Clinical photo
164 ENT Surgery Phono Surgery for Vocal cord paralysis (S2B2.2) CT scan/ MRI Clinical photo
165 ENT Surgery Laryngo Fissurectomy (S2B2.3) CT scan Clinical photo
166 ENT SurgeryUvulo-Palato Pharyngoplasty
(S2B2.7)Polysomnography, CT/MRI Clinical photo
167 ENT SurgeryStapedectomy + Veingraft
(S2B3.4)
CT Temporal Bone, PTA, Impedance
audiometryClinical photo with Piston
168 ENT Surgery Angiofibroma Nose (S2B3.6) CT PNS, DNE Clinical photo
169 ENT Surgery Endoscopic DCR (S2B3.7) Clinical photo Clinical photo
170 GastroenterologyOesophageal Perforation- 7
Days Stay (M14V1.2)CT SCAN THORAX and Abdomen CT- ABDOMEN optional
171 Gastroenterology Biliary Stricture 3) Sclerosing Cholangitis 7 Days Stay (M14V1.18)MRCP/ ERCP, Per cutaneous Transhepatic/
Endoscopic Billiary Drainage, , USG
Post treatment evidence of radiological and
endoscopic image/ video
172 GastroenterologyBiliary Structure 2) Post Op
Leaks 7 Days Stay (M14V1.17)
MRCP/ ERCP, Per cutaneous Transhepatic Billiary/
Endoscopic Drainage, USG
ENDOSCOPIC IMAGE/ video
RADIOLOGICAL
173 GastroenterologyBiliary Structure 1) Post Op
Stent 7 Days Stay (M14V1.16)
MRCP/ ERCP, Per cutaneous Transhepatic Billiary/
Endoscopic Drainage, USG
ENDOSCOPIC IMAGE/ video
RADIOLOGICAL
174 Gastroenterology Cirrhosis With Hepatic Encephalopathy -11 Days Stay (M14V1.14)USG / ascitic fluid analysis, LFT, Sr Ammonia, PT-
INR, UGI Endoscopy(optional)
Post procedure clinical photograph and lab
invistigations, (LFT)
175 GastroenterologyObscure GI Bleed1 Week Stay
(M14V1.13)
CAPSULE ENDOSCOPY/ CT enterography/ Barium
Meal Follow Through, ENTEROSCOPY BIOPSY
(optional)
ENDOSCOPIC PHOTOGRAPH/ Lab investigations
176 Gastroenterology Chronic Pancreatitis With Severe Pain - 7 Days Stay (M14V1.12)CT Scan abdomen/ USG/ EUS / ERCP/ MRCP
RBS, Etiology of pancreatitis,LFT,RFT
post treatment Lab investigation WBC Count,Sr.
Amylase, Lipase which are repeated at an
interval of 48 hours of admission,LFT : esp.
AST,Blood Sugar Level,RFT: Urea & Creatinine
level,Sr Calcium level,USG Abdomen /CT Scan
Abdomen,APACHE Score at time of admission
& 48 hrs post admission,Diet Chart
177 Gastroenterology Acute Pancreatitis With Pseudocyst (Infected) 3 Weeks Stay(M14V1.11)S. AMYLASE, Sr Lipase, EUS/ CT- ABDOMEN, USG,
CBC
LAB INVESTIGATIONS(S. AMYLASE/ Sr Lipase),
USG
178 GastroenterologyAcute Pancreatitis (Severe) -3
Weeks Stay(M14V1.10)
CT Abdomen/ EUS, Sr AMYLASE, Sr Lipase, LFT,
electolytes , RANSON Scoring/ BISAP Scoring, RFT,
RBS, Etiology of pancreatitis
Post Treatment Evidence Of Usg. Lab
Investigation ( Sr. Amylase/Sr. Lipase ) Wbc
Count,Sr. Amylase, Lipase Which Are Repeated
At An Interval Of 48 Hours Of Admission,Lft :
Esp. Ast,Blood Sugar Level,Rft: Urea &
Creatinine Level,Sr Calcium Level,Usg Abdomen
/Ct Scan Abdomen, Ranson/Bisap Score At Time
of Admission ,Diet Chart
179 GastroenterologyAcute Pancreatitis (Mild) - 1
Week Stay With Post Treatment Evidence Of (M14V1.9)
CT Abdomen/ EUS, Sr AMYLASE, Sr Lipase, LFT,
electolytes , RANSON Scoring/ BISAP Scoring, RFT,
RBS, Etiology of pancreatitis
Post Treatment Evidence Of Usg. Lab
Investigation ( Sr. Amylase/Sr. Lipase ) Wbc
Count,Sr. Amylase, Lipase Which Are Repeated
At An Interval Of 48 Hours Of Admission,Lft :
Esp. Ast,Blood Sugar Level,Rft: Urea &
Creatinine Level,Sr Calcium Level,Usg Abdomen
/Ct Scan Abdomen,Ranson/Bisap Score At Time
Of Admission ,Diet Chart
180 GastroenterologyGastric Varices 3 Days Stay
(M14V1.8)UGI ENDOSCOPY ENDOSCOPIC PHOTOGRAPH
181 Gastroenterology Oesophageal Varices, Sclerotherapy- One Day Stay (M14V1.5) UGI ENDOSCOPY ENDOSCOPIC PHOTOGRAPH
182 GastroenterologyCorrosive Oesophageal injury
(M13V1.20)clinical history of acid ingestion
post treatment evidence of
Barium swallow / UGI scopy optional, MLC
183 GastroenterologyOesophageal foreign body
(M13V1.1)X-Ray
post treatment evidence of
Endoscopic Photograph
184 Gastroenterology Achalasia cardia (M13V1.3) UGI endoscopy / Barium swallowpost treatment evidence of
Endoscopic Photograph/ Barium Swallow
185 Gastroenterology Oesophageal Varices, variceal banding (M13V1.4) UGI endoscopypost treatment evidence of
Endoscopic Photograph
186 Gastroenterology Oesophageal Fistula (M13V1.6) CT Thoraxpost treatment evidence of
Photograph of stent in position
187 GastroenterologyGAVE (Gastric Antral Vascular
Ectasia) (M13V1.7)UGI Endoscopy
post treatment evidence of
Endoscopic Photograph
188 Gastroenterology Cirrhosis with hepato renal syndrome (M13V1.15)Reports of Serum Chemistry USG/CT ABDOMEN IS
MANDATORY AT TIME OF PREAUTH
post treatment evidence of
Lab Investigation
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
189General
Medicine
Thrombocytopenia With
Bleeding Diathesis (M16Q1.1)CBC (platelet count), PT INR, BT, CT Post procedure Evidence of clinical imrovement
190General
Medicine
Haemophilia treatment with IV FPP, Factor VIII /Cryoprecipitate
(M16Q1.2)
VON WILL BRANDS / FACTOR VIII/ IX ASSAY
Coagulation Parameters
Post Procedure Evidence Of Clinical
Imrovement , Case Sheet With Records Of
Factor Given
191General
Medicine
Metabolic Coma Requiring
Ventilatory Support (M16Q1.9)
Machine generated ABG, ECG, Blood Urea, Blood
sugar, Sr. Creat, Sr. Electrolites, LFT, clinical photo
with ventilatory support
Post treatment evidence of clinical
improvement, Vit B12 level / Lab investigations
192General
Medicine
Scorpion Sting Requiring
Ventilator Support (M16Q1.8)Serial ABG, Serial blood sugar, ECG
Post treatment evidence of clinical
improvement & RFT investigations
193General
Medicine
Snake Bite Requiring Ventilator
Support (M16Q1.7)
Serial ABG, Serial blood sugar, ECG, PT/PTTK/ DIC
profile RFT
Post treatment evidence of clinical
improvement & CPK, Lab investigations
194General
MedicineTb Meningitis (M16Q1.6)
CT Scan-Brain, CSF Analysis, Chest
X-Ray
Post treatment evidence of clinical
improvement & Lab investigations, CSF
195General
MedicineCerebral Malaria (M16Q1.5)
Test for detection of Malarial
Parasite/ Rapid test, CBC,
Post treatment evidence of clinical
improvement & Lab investigations
196General
Medicine
Chelation Therapy For
Thalassemia (M16Q1.4)Haemogram, Hb Electrophoresis, Serum Ferritin
Post treatment evidence of clinical
improvement & LFT, Lab investigations
197General
Medicine
Other Coagulation Disorders with Von Wili Brand Factor: treatment
with IV FPP, Factor VIII /Cryoprecipitate (M16Q1.3 )Von Willi Brands Factor, Coagulation Parameters
Post Procedure Evidence Of Clinical
Imrovement, Fdp(Fibrin Degradation Products)
Levels, Lab Investigations
198 General surgeryExcision Of Thyroglossal Cyst
Fistula (S1A1.19)CLINICAL PHOTOGRAPH, USG
Histopath report,Post procedure clinical
photograph
199 General surgery Parathyroidectomy (S1A1.18) USGHistopath report,Post procedure clinical
photograph
200 General surgeryCystic Hygroma Excision-Minor
(S1A1.16)CLINICAL PHOTOGRAPH
Histopath report,Post procedure clinical
photograph
201 General surgeryCystic Hygroma Excision-Major
(S1A1.15)CLINICAL PHOTOGRAPH
Histopath report,Post procedure clinical
photograph
202 General surgery Wedge Excision (S1A1.14) CLINICAL PHOTOGRAPH Histopath report
203 General surgery Cystic Hygroma Excision- Extensive (S1A1.10) USG,CLINICAL PHOTOGRAPHHistopath report,Post procedure clinical
photograph
204 General surgery Partial Glossectomy (S1A1.9) BIOPSY, CLINICAL PHOTOGRAPHHistopath report,Post procedure clinical
photograph
205 General surgery Hemimandibulectomy (S1A1.6) X- RAY Clinical Photo, X- RAY, biopsy
206 General surgeryBranchial Sinus Excision
(S1A1.5)CLINICAL PHOTOGRAPH
Histopath report,Post procedure clinical
photograph
207 General surgeryRemoval Of Submandibular
Salivary Gland (S1A1.3)CLINICAL PHOTOGRAPH
Histopath report,Post procedure clinical
photograph
208 General surgery Brachial Cyst Excision (S1A1.1) CLINICAL PHOTOGRAPHHistopath report,Post procedure clinical
photograph
209 General surgeryOperation For Hydatid Cyst
Liver (S1A10.1)USG/CT Histopathology report
210 General surgeryPortocaval Anastomosis
(S1A10.2)MRI/ USG/ UGI ENDOSCOPY ENDOSCOPY/ USG
211 General surgery Repair Of CBD (S1A11.7) CT/USG, LFT USG Post procedure clinical photograph
212 General surgery Cystogastrostomy (S1A11.6) CT/USG, LFT
Post procedure clinical photograph,USG
intra op photographic e/o surgery mandatory
for claim
213 General surgery Cystojejunostomy (S1A11.5) CT/USG, LFT
Post procedure clinical photograph,USG
intra op photographic e/o surgery mandatory
for claim
214 General surgeryLap Cholecystostomy With
Exploration CBD (S1A11.4)CT/USG, LFT
Post procedure Evidence of clinical imrovement
& Lab investigations, USG
post op HP for claim
215 General surgery Cholecystectomy & Exploration CBD (S1A11.3) CT/USG, LFT Post procedure clinical photograph,USG
216 General surgeryLap.Cholecystectomy
(S1A11.2)CT/USG, LFT
Post procedure clinical Potograph,VIDEO,USG
post op HP for claim
217 General surgery Cholecystectomy (S1A11.1) CT/USG, LFTPost procedure clinical
photograph,USG post op HP for claim
218 General surgerySplenectomy For
Hypersplenism (S1A13.1)CT/USG, PERIPHERAL SMEAR
Post procedure clinical
photograph,histopathology report
219 General surgery Colostomy Closure (S1A14.8)CLINICAL PHOTOGRAPH, Barium
StudyPost procedure clinical photograph
220 General surgery Colostomy (S1A14.7) USG/ CT, ENDOSCOPY/ Sketch Post procedure clinical photograph
221 General surgery Total Colectomy (S1A14.6)BARIUM, USG/ CT, ENDOSCOPY/
SketchPost procedure clinical photograph,BIOPSY
222 General surgeryOperation For Volvulus Of
Large Bowel (S1A14.2)CT-CONTRAST, X-RAY ABDOMEN X- RAY/Post procedure clinical photograph
223 General surgeryMal-Rotation & Volvulus Of
The Midgut (S1A14.1)CT, X-RAY ABD X- RAY/Post procedure clinical photograph
224 General surgery Total Thyroidectomy (S1A2.6) Thyroid Function Test, FNAC/USGHistopath report,Post procedure clinical
photograph
225 General surgerySubtotal Thyroidectomy
(S1A2.5)FNAC/ USG, T F T
Histopath report,Post procedure clinical
photograph
226 General surgery Resection Enucleation (S1A2.4)FNAC , T F T , USG/ Thyroid
Scan(optional)BIOPSY,Post procedure clinical photograph
227 General surgery Simple Mastectomy(Nm) (S1A3.1) MAMMOGRAPHY, FNAC BIOPSY, Post procedure clinical photograph
228 General surgeryVentral And Scar Hernia With
Mesh (S1A4.9)CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph
229 General surgery Scar Hernia Without Mesh (S1A4.8) CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
230 General surgeryUmbilical Hernia Hernia With
Mesh (S1A4.7)CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph
231 General surgeryUmbilical Hernia Without
Mesh (S1A4.6)CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph
232 General surgery
Rare Hernias
(Spigalion,Obuturator, Sciatic)
(S1A4.5)
CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph
233 General surgeryHiatus Hernia Repair
Abdominal (S1A4.4)USG ABDOMEN, UGI ENDOSCOPY/ Sketch Post procedure clinical photograph
234 General surgery Femoral Hernia (S1A4.3) CLINICAL PHOTOGRAPH Post procedure clinical photograph
235 General surgeryEpigastric Hernia With Mesh
(S1A4.2)CLINICAL PHOTOGRAPH, Post procedure clinical photograph
236 General surgeryEpigastric Hernia Without
Mesh (S1A4.1)CLINICAL PHOTOGRAPH, Post procedure clinical photograph
237 General surgeryAppendicular Perforation
(S1A5.2)X-ray Abdomen, USG
BIOPSY, Post procedure clinical photograph, Pus
C/S
238 General surgery Lap. Appendectomy (S1A5.1) USG Histopath,video,clinical photo
239 General surgeryHighly Selective Vagotomy
(S1A7.1)ENDOSCOPY/ Sketch Post procedure clinical photograph
240 General surgery Gastrostomy Closure (S1A7.10) CLINICAL PHOTOGRAPH Post Procedure Clinical Photograph
241 General surgery Duodenal Perforation (S1A7.2) USG/ CT- ABDOMEN, X-RAY Post procedure clinical photograph
242 General surgerySelective Vagotomy Drainage
(S1A7.3)ENDOSCOPY/ Sketch Post procedure clinical photograph
243 General surgeryVagotomy Pyloroplasty
(S1A7.4)ENDOSCOPY/ Sketch Post procedure clinical photograph
244 General surgery Gastrojejunostomy & Vagotomy (S1A7.5) ENDOSCOPY-VIDEO PHOTO/ Sketch Post procedure clinical photograph
245 General surgeryOperation For Bleeding Peptic
Ulcer (S1A7.6)ENDOSCOPY/ Sketch Post procedure clinical photograph
246 General surgeryPartial/Subtotal Gastrectomy
For Ulcer (S1A7.7)ENDOSCOPY/ Biopsy / Barium meal Post procedure clinical photograph
247 General surgery Pyloromyotomy (S1A7.8) ENDOSCOPY / Sketch Post procedure clinical photograph
248 General surgery Gastrostomy (S1A7.9) BIOPSY,USG, ENDOSCOPY/ Sketch Post procedure clinical photograph
249 General surgery Intussusception (S1A8.1) X-RAY ABD, USG / CT abd Post procedure clinical photograph, BIOPSY
250 General surgeryOperation For Acute Intestinal
Obstruction (S1A8.2)X-RAY ABD, USG / CT abd Post procedure clinical photograph, BIOPSY
251 General surgeryOperation For Acute Intestinal
Perforation (S1A8.3)X-RAY ABD, USG / CT abd Post procedure clinical photograph, BIOPSY
252 General surgeryOperation For Haemorrhage
Of The Small Intestine (S1A8.4)CT WITH CONTRAST Post procedure clinical photograph, BIOPSY
253 General surgeryOperations For Recurrent Intestinal Obstruction (Noble Plication Other)
(S1A8.5)CT-CONTRAST / USG, Xray Post procedure clinical photograph, BIOPSY
254 General surgeryResection & Anastomosis Of
Small Intestine (S1A8.6)CT/ USG, X-RAY ABD Post procedure clinical photograph, BIOPSY
255 General surgery Ileostomy (S1A8.7) CT abd / USG Post procedure clinical photograph, HP Report
256 General surgery Ileostomy Closure (S1A8.8) CLINICAL PHOTOGRAPH Post procedure clinical photograph
257 General surgeryPull Through Abdominal
Resection (S1A9.1)CLINICAL PHOTOGRAPH
Post procedure clinical photograph, Rectal
Biopsy
258 General surgery Anterior Resection (S1A9.2)BIOPSY, COLONOSCOPY, CLINICAL
PHOTOGRAPHPost procedure clinical photograph, BIOPSY
259 General surgery Cervical Rib excision (S1A1.2) Color Doppler , X-RAY Post procedure evidence of X-Ray
260 General surgery Parotid Duct repair (S1A1.4) Silography Post procedure evidence of Silography
261 General surgery Abbe Operation (S1A1.11) CLINICAL PHOTOGRAPH Post procedure clinical photograph
262 General surgery Segmental Mandible Excision (S1A1.7) X- RAY Clinical Photo, X- RAY
263 General surgeryCarotid Body-tumours
Excision (S1A1.8)Clinical Photograph , USG Neck/ Color doppler
Post procedure evidence of Clinical Photograph,
Biopsy
264 General surgery Vermilionectomy (S1A1.12) CLINICAL PHOTOGRAPH Post procedure clinical photograph
265 General surgery Wedge Excision & Vermilionectomy (S1A1.13) CLINICAL PHOTOGRAPHHistopath report,Post procedure clinical
photograph
266 General surgery Hemithyroidectomy (S1A2.1)FNAC , T F T , USG, Thyroid
Scan(optional)
Histopath report,Post procedure clinical
photograph
267 General surgery Isthmectomy (S1A2.2)FNAC , T F T , USG, Thyroid
Scan(optional)
Histopath report,Post procedure clinical
photograph
268 General surgery Partial Thyroidectomy (S1A2.3)FNAC , T F T , USG, Thyroid
Scan(optional)
Histopath report,Post procedure clinical
photograph
269 General surgeryExcision of Lingual Thyroid
(S1A1.20)Clinical Photograph , Isotope Scan
Histopath report,Post procedure clinical
photograph
270 General surgery Operation of the Duplication of the intestines (S1A14.3) CT-Contrast/ USG Post procedure evidence of Clinical photograph
271 General surgery Right Hemi Colectomy (S1A14.5)Barium / CT , Endoscopy , Biopsy,
USG
Post procedure evidence of Clinical
photograph/Biopsy
272 General surgery Left Hemi Colectomy (S1A14.4)Barium / CT , Endoscopy , Biopsy,
USG
Post procedure evidence of Clinical
photograph/Biopsy
273 General surgery Operation on Adrenal glands, unilateral for tumour (S1A12.2) Biochemical Investigations , CT , USG Post procedure evidence of USG,Biopsy
274 General surgery Operation of Adrenal glands, bilateral for tumour (S1A12.1) Biochemical Investigations , CT , USG Post procedure evidence of USG,Biopsy
275 General surgery Splenorenal Anastomosis (S1A13.2) MRI , UGI Endoscopy , USG Post procedure evidence of USG, Endoscopy
276 General surgery Warren shunt (S1A13.3) MRI , UGI Endoscopy , USG Post procedure evidence of USG,Endoscopy
277 Genitourinary systemRenal transplantation surgery Inv - USG,RFT Post procedure evidence of
Clinical photograph (S9H1.2)
RFT, USG HOTA certificate for pre auth is
mandatory(for 1st case of transplant only in that
hospital)
OT Notes, Post procedure clinical photograph/
USG
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
278 Genitourinary system
A.V. Fistula (Pretransplant procedure only) Inv - Renal function tests,
Serum electrolytes Post procedure evidence of Clinical photograph
(S9H1.1)
RENAL FUNCTION TESTS, SERUM ELECTROLYTES Post procedure clinical photograph
279Genitourinary
systemTorsion Testis (S9H2.2) USG Post procedure clinical photograph
280Genitourinary
systemOrchidopexy Bilateral (S9H2.1) USG/ Clinical photograph Post procedure clinical photograph
281 Genitourinary systemLaparoscopic Pyelolithotomy
(S9H3.4)USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo
282 Genitourinary system Open Cystolithotomy (S9H3.3) USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo
283 Genitourinary systemOpen Nephrolithotomy
(S9H3.2)USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo
284 Genitourinary system Open Pyelolithotomy (S9H3.1) USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo
285Genitourinary
systemDj Stent (One Side) (S9H4.6) USG/KUB/IVP/ CT Abd X- RAY
286 Genitourinary system Nephrostomy (S9H4.5) USG/KUB/IVP/ CT AbdPost procedure clinical photograph post op x
ray kub mandatory for claim
287Genitourinary
systemURSL (S9H4.4) USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo
288Genitourinary
systemESWL (S9H4.3) USG/KUB/IVP/ CT Abd
during procedure photo . X
ray/USG
289Genitourinary
systemPCNL (S9H4.2) USG/KUB/IVP/ CT Abd X ray/USG, clinical Photo
290Genitourinary
systemCystolithotripsy (S9H4.1) USG/KUB/IVP/ CT Abd USG / X ray
291 Genitourinary systemHypospadius Adult Double
Stage - TURBT (S9H5.8)Clinical photgraph Clinical Photgraph
292 Genitourinary system Urethroplasty For Stricture Urethra Double Stage Reconstruction Procedure (S9H5.4)clinical photo, RGU clinical photo
293 Genitourinary system Post-Transplant immunosuppressive Treatment from 7th to 12 th Month after transplantation (S9H6.1)RFT, USG BILLS COPY
294 Genitourinary systemAnderson Hynes Pyeloplasty
(S9H10.2)X ray, USG, IVP/ CT abd clinical photo
295 Genitourinary systemAnatrophic Pyelolithotomy For
Staghorn Calculus (S9H10.1)X ray, USG, IVP/ CT abd Post procedure clinical photograph, X- RAY/USG
296 Genitourinary systemEndoscope Removal Of Stone
In Bladder (S9H7.9)USG/KUB/IVP/ CT Abd
ENDOSCOPIC PHOTOGRAPH, USG/Xray
KUB
297Genitourinary
systemRenal Cyst Excision (S9H7.8) USG USG, histopath, Intra op Photo
298 Genitourinary system Nephrectomy Pyonephrosis/ XGP (S9H7.2)
IVP, USG/CT Abd
urine routine microscopy mandatory for pre
auth.
USG/ Biopsy
299 Genitourinary system Nephrostomy (S9H7.1) IVP, USG/CT AbdUSG/Xray post op photo of nephrostomy
required for claim
300 Genitourinary systemUreteric Reimplantation
(S9H8.6)IVP/ MCU, USG Intra op Photo, Post op Xray
301Genitourinary
system
Closure Of Urethral Fistula
(S9H8.3)
Retrograde Urethrogram, Clinical
photographPost procedure clinical photograph
302Genitourinary
system
Epispadiasis - Correction
(S9H8.2)CLINICAL PHOTOGRAPH Post procedure clinical photograph
303Genitourinary
systemVasico Vaginal Fistula (S9H8.1) IVP/MCU, Scopy clinical notes,
304 Genitourinary system Incontinence Urine (Male) (S9H9.7)
U.SCOPY, USG, UDS (optional),If USG is normal
then UDS ( Uro Diynamic study ) is to be done to
confirm the dignosis.
USG
305 Genitourinary system Incontinence Urine (Female) (S9H9.6)
USG, UDS optional
If USG is normal then UDS ( Uro Diynamic study )
is to be done to confirm the dignosis.
USG
306Genitourinary
systemTURP Cyst Lithotripsy (S9H9.1) USG with prostate size, PSA Biopsy, post op specimen photo
307Genitourinary
systemChordae correction (S9H2.3) Clinical photo Post procedure evidence of Clinical photograph
308 Genitourinary system Partial amputation of Penis(Non-Malignant) (S9H2.4) Clinical PhotographHistopath report,Post procedure clinical
photograph
309 Genitourinary system Total amputation of Penis(Non-Malignant) (S9H2.5) Clinical PhotographHistopath report,Post procedure clinical
photograph
310 Genitourinary system Optical Urethrotomy (S9H8.4) X-Ray, RGUPost procedure evidence of Intra operative
Endoscopic picture
311 Genitourinary system Urethroplasty for Stricture Urethra Single stage (S9H5.1) RGU Post procedure evidence of Clinical photograph
312 Genitourinary system Urethroplasty for Stricture Urethra Double Stage Stage -1 (S9H5.2) RGU Post procedure evidence of Clinical photograph
313 Genitourinary system Urethroplasty for Stricture Urethra Double Stage Stage -2 (S9H5.3)Clinical photo
RGU is mandatory for preauthPost procedure evidence of Clinical photograph
314 Genitourinary system Hypospadius Adult Single Stage (S9H5.5) Clinical Photograph Post procedure evidence of Clinical photograph
315 Genitourinary system Hypospadius Adult Double Stage - Stage-1 (S9H5.6) Clinical Photograph Post procedure evidence of Clinical photograph
316 Genitourinary system Hypospadius Adult Double Stage - Stage-2 (S9H5.7) Clinical Photograph Post procedure evidence of Clinical photograph
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
317 Genitourinary system Post-Transplant immunosuppressive Treatment from 1st to 6th Month after transplantation (S9H 1.3)RFT,USG BILLS COPY
318Genitourinary
systemSimple Nephrectomy (S9H7.3) USG, CT scan/IVP
Post procedure evidence of USG, histopath
report
319Genitourinary
system
Lap. Nephrectomy Simple
(S9H7.4)USG, CT scan Post procedure evidence of USG, Biopsy
320Genitourinary
system
Lap. Nephrectomy Radical
(S9H7.5)USG, CT scan Post procedure evidence of USG, Biopsy
321Genitourinary
system
Lap. Nephrectomy Partial
(S9H7.6)USG, CT scan Post procedure evidence of USG, Biopsy
322 Genitourinary systemBilateral Nephroureterectomy
(S9H7.7)USG, IVP Post procedure evidence of USG
323 Genitourinary systemPerineal Urethrostomy
(S9H8.5)X-Ray, RGU Post procedure evidence of clinical picture
324Genitourinary
system
Ileal Conduit formation
(S9H8.7)CT abd Post procedure evidence of Clinical photograph
325 Genitourinary system Ureterocele (S9H8.8) X Ray/ IVP/MCUPost procedure evidence of intra operative
Clinical photograph
326 Genitourinary system Transurethral resection of prostate (TURP) (S9H8.9)
USG with prostate size, PSA
USG WITH POST VOID VOLUME AT TIME OF
PREAUTH
Biopsy, post op specimen photo
327Genitourinary
systemOpen prostatectomy (S9H9.2) USG with prostate size, PSA Histopath, post op specimen photo
328Genitourinary
systemCaecocystoplasty (S9H9.3) USG, IVP/ MCU
Post procedure evidence of USG, clinical
photograph
329 Genitourinary system Total cystectomy (S9H9.4) USG, CT abdPost procedure evidence of USG ,Histopath
clinical photo
330 Genitourinary system Diverticulectomy (S9H9.5) USG, MCU, U.Scopy optionalPost procedure evidence of USG ,Histopath
clinical photo
331Gynaecology and
Obstetrics SurgeryAbruptioo placenta with coagulation defect – (S4C1.4)
USG / (APTT, S.FIBRINOGEN LEVEL, PT, PLATELET
COUNT, HAEMATOCRIT) Coagulation profile, LFT,
RFT
CLINICAL PHOTOGRAPH OF RETROPLACENTAL
CLOTS, USG
332Gynaecology and
Obstetrics Surgery
Eclampsia with complication requiring ventilatory support Inv –
(S4C1.3)
ABG, (S.FIBRINOGEN LEVEL, PT, PLATELET COUNT,
HAEMATOCRIT, APTT) / Sr. Uric acid , Sr. Creat,
Urine albumin , LFT/RFT
BIOCHEMICAL INVESTIGATIONS, Post procedure
clinical photograph
333Gynaecology and
Obstetrics SurgeryRupture Uterus (S4C1.2) USG USG, Clinical photograph/ HPE
334Gynaecology and
Obstetrics Surgery
Caesarean Hysterectomy with
Bladder Repair (S4C1.1)USG USG, PHOTOGRAPH
335Gynaecology and
Obstetrics Surgery
Vaginal Hysterectomy
(S4C2.17)USG HPE report
336Gynaecology and
Obstetrics Surgery
Laparoscopic adhesolysis
(S4C2.16)USG
HPE / VIDEO/ Sketch, USG Video is mandatory.
Sketch is not acceptable
337Gynaecology and
Obstetrics Surgery
Laparoscopic Sling operations
(S4C2.15)USG
VIDEO/ Sketch, USG/ HPE Video is mandatory.
Sketch is not acceptable
338Gynaecology and
Obstetrics Surgery
Laparoscopic recanalisation
(S4C2.14)evidence of blockage, HSG
VIDEO/Sketch, /USG Video is mandatory.
Sketch is not acceptable
339Gynaecology and
Obstetrics Surgery
Laparoscopic Myomectomy
(S4C2.13)USG
HPE, VIDEO/ Sketch, / USG Video is mandatory.
Sketch is not acceptable
340Gynaecology and
Obstetrics SurgeryLaparoscopic ovarian drilling(S4C2.12) USG Usg , Video Is Mandatory.
341Gynaecology and
Obstetrics Surgery
Laparoscopic Ectopic Resection
(S4C2.11) USG Hpe, Usg,Video Is Mandatory.
342Gynaecology and
Obstetrics Surgery
Laparoscopic Cystectomy
(S4C2.10)USG HPE, Video is mandatory.
343Gynaecology and
Obstetrics SurgeryVault prolapse abdominal repair with mesh (S4C2.9) USG USG, Intra Op Photo showing Mesh
344Gynaecology and
Obstetrics SurgeryVault prolapse abdominal repair (S4C2.8) USG USG, Sketch
345Gynaecology and
Obstetrics SurgerySlings with mesh repair for prolapse (S4C2.7) USG USG, Sketch
346Gynaecology and
Obstetrics SurgeryMc Indo-s repair for Vaginal Atresia (S4C2.6) USG USG, Sketch
347Gynaecology and
Obstetrics SurgeryPelvic floor Reconstruction with mesh (S4C2.5) USG USG, Sketch
348Gynaecology and
Obstetrics SurgeryCystocele ,Rectocele & Perineorraphy (S4C2.4) USG USG, Sketch
349Gynaecology and
Obstetrics SurgeryVaginal Hysterectomy with Mesh repair (S4C2.3) USG HPE
350Gynaecology and
Obstetrics SurgeryVaginal Hysterectomy with pelvic floor repair (S4C2.2) USG HPE
351Gynaecology and
Obstetrics SurgeryLAVH (S4C2.1) USG HPE
352Infectious
DiseaseTetanus Severe (M5R1.1)
Clinical Photo of posture,
ABG
clinical photograph Post treatment e/o clinical
improvement,Swab for C/S
mandatory
353Infectious
DiseaseDiphtheria complicated (M5R1.2) ECG, Clinical photograph, Throat swab for C/S Lab investigations
354Infectious
DiseaseCryptococcal Meningitis (M5R1.3)
Investigation foe cryptococcal antigen/ CSF India
ink preparationLab investigations
355Interventional
RadiologyInferior Vena Cava Stenting Single Stent (M15W1.1) USG/ CT scan/ DSA IVC Gram
Post procedure
Angiographic Image
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
356Interventional
Radiology
Hepatic Vein Stenting In Budd - Chiari Syndrome Single Stent (M15W1.
2)CT/MRI Liver
Post procedure Angiographic Image Doppler is
mandatory for claims
357Interventional
Radiology
Acute Stroke Thrombolysis
With RTPA (M15W1.3)CT/ CT-perfusion/ MRI CT, Post Procedure DSA
358Interventional
Radiology
Renal Artery Embolization With Multiple Coils And Microcatheter
(M15W1.4)CT-Angiogram/ DSA Angiogram
Post procedure
Angiograpgic Image
359Interventional
Radiology
Cortical Venous Sinus
Thrombolysis (M15W1.5)CT/ MRI
Post procedure clinical Photograph,
Radiographic Image/CD
360Interventional
Radiology
Deep Venous Thrombolysis For
DVT With IVC Filter (M15W1.6)Color Doppler/ Clinical Photograph
Post procedure clinical photograph, Doppler/
Venographic DSA Image
361Interventional
Radiology
Subclavian, Iliac, Superficial Femoral Artery Stenting Each With One
Stent (M15W1.7)Angiogram / Doppler
Post procedure clinical photograph,
Radiographic Image/CD Stent sticker, Claims
approval subject to stent visiblity and
restoration of arterial lumen in angioplasty
video.
362Interventional
Radiology
Tibial Angioplasty In Critical
Limb Ischemia (M15W1.8)Angiogram / Doppler
Post procedure clinical photograph,
Radiographic Image/CD
363Interventional
Radiology
Mesenteric Artery Angioplasty
& Stenting In Acute & Chronic Mesenteric Ischemia - Single Stent
(M15W1.9)
Angiogram / CT angio
Post procedure clinical photograph,
Radiographic Image/CD Stent sticker, Claims
approval subject to stent visiblity and
restoration of arterial lumen in angioplasty
video.
364Interventional
Radiology
Gastrointestinal Visceral Arterial Embolization In Upper And Lower
Gastrointestinal Bleeding With Microcatheter (M15W1. 10)USG Intra -op Video
365Interventional
Radiology
Bronchial Artery Embolization In Hemoptysis Using PVA And Micro
Catheter (M15w1.11)X-ray /CT chest Intra -op Video
366Interventional
Radiology
Radiofrequency Tumour
Ablation Therapy (M15W1.12)USG/CT/ MRI
Post procedure CT/MRI
scan
367Interventional
Radiology
Embolization Of Postoperative And Post Traumatic Bleeding (M15W1.
13)clinical photo req at the time of preauth
Post procedure clinical photograph,
Radiographic Image/CD
368Interventional
Radiology
Inferior Vena Cava Filter
Placement (M15W1.14)
COLOR DOPPLER/PERIPHERAL ANGIOGRAM IS
MANDATORY AT TIME OF PREAUTH
Post procedure clinical photograph,
Radiographic Image/CD
369Interventional
Radiology
Biliary Drainage Procedures - External Drainage And Stent Placement -
Single Metallic Stent (M15W1.15)CT/MRI/ USG/ERCP req at the time of preauth
Post procedure clinical photograph,
Radiographic Image/CD STENT STICKER AT TIME
OF CLAIMS MANDATORY
370Interventional
RadiologyNephrostomy Tube And Nephroureteral Stent Placement (M15W1.16) USG/CT IS MANDATORY AT TIME OF PREAUTH.
Post procedure clinical photograph,
Radiographic Image/CD
371Interventional
Radiology
Uterine Artery Embolization In
Severe Menorrhagia
Secondary To PPH, Uterine
Fibroids And AVM (M15W1.17)
USG/CT IS MANDATORY AT TIME OF PREAUTH.Post procedure clinical photograph,
Radiographic Image/CD
372Interventional
Radiology
Intra-Arterial Thrombolysis For
Acute Ischemic Limbs
(M15W1. 18)
COLOR DOPPLER/PERIPHERAL ANGIOGRAM IS
MANDATORY AT TIME OF PREAUTH
Post procedure clinical photograph,
Radiographic Image/CD
373Interventional
Radiology
Permanent Tunnelled Catheter
Placement As Substitute For AV Fistula In Long Term Dialysis
(M15W1.19)
COLOR DOPPLER/PERIPHERAL ANGIOGRAM IS
MANDATORY AT TIME OF PREAUTH
Post procedure clinical photograph,
Radiographic Image/CD
374Interventional
Radiology
Central Venous Stenting For Central Venous Occlusion (
Brachiocephalic, Subclavian Vein And Sup Vena Cava) Single Metallic
Stent (M15W1. 20)
COLOR DOPPLER IS MANDATORY AT TIME OF
PREAUTH.
Post procedure clinical photograph,
Radiographic Image/CD STENT STICKER AT TIME
OF CLAIMS MANDATORY
375Interventional
Radiology
Endovascular Intervention For Salvaging Hemodialysis AV Fistula
(M15W1.21)
COLOR DOPPLER IS MANDATORY AT TIME OF
PREAUTH
Post procedure clinical photograph,
Radiographic Image/CD
376Interventional
Radiology
Balloon Retrograde Transvenous Obliteration Of Bleeding Gastric
Varices ( BRTO) (M15W1.22)clinical history
Post procedure clinical photograph,
Radiographic Image/CD
377Interventional
RadiologyPreoperative Portal Vein Embolization For Liver Tumors (M15W1. 23) USG/CT IS MANDATORY AT TIME OF PREAUTH.
Post procedure clinical photograph,
Radiographic Image/CD
378Interventional
Radiology
Chemo Embolization For Liver Tumors Using Drug And PVA Or DC Beads
(M15W1.24)USG/CT IS MANDATORY AT TIME OF PREAUTH.
Post procedure clinical photograph,
Radiographic Image/CD
379Interventional
Radiology
Percutaneous Vertebro Plasty/ Cementoplasty (For Each
Level) Post Procedure Evidence Of Clinical Photograph And
Radiographic Image (M15W1.25)
ANGIOGRAM IS MANDATORY AT TIME OF
PREAUTH
Post procedure clinical photograph,
Radiographic Image/CD
380Interventional
RadiologyTrans Jugular Intrahepatic Portosystemic Shunt (TIPSS) (M15W1. 26)
MRI/COLOR DOPPLER MANDATORY AT TIME OF
PREAUTH
Post procedure clinical photograph,
Radiographic Image/CD
381Interventional
Radiology
Embolization Of Pulmonary AV Malformation Post Procedure Evidence
Of Clinical Photograph And Radiographic Image (M15W1.27)CT/MRI MANDATORY AT TIME OF PREAUTH
Post procedure clinical photograph,
Radiographic Image/CD
382Interventional
RadiologyPreoperative Prophylactic Tumor Embolization (M15W1. 28) CT/MRI req at the time of preauth
Post Procedure Clinical Photograph,
Radiographic Image/Cd
383Interventional
Radiology
Embolization Of AV Malformation Of Brain Per Sitting With Onyx
(M15W1.29)CT/MRI MANDATORY AT TIME OF PREAUTH
Post procedure clinical photograph,
Radiographic Image/CD
384Interventional
RadiologyCarotid Stenting Single Stent With Protection Device (M15W1. 30) MRI/CT- Angiogram, Doppler
Post Porocedure DSA Stent sticker, Claims
approval subject to stent visiblity and
restoration of arterial lumen in angioplasty
video.
385Interventional
RadiologyIntracranial Arterial And Venous Stenting (M15W1.31) MRI/CT- Angiogram Post Procedure DSA
386Interventional
Radiology
Peripheral Stent Graft For Peripheral Aneurysms And Av Fistulae
(M15W1.32)CT or Doppler Post procedure angiography picture
387Interventional
RadiologyEmbolization Of Caratico- Cavernous Fistula (M15W1.33) CT/MRI MANDATORY AT TIME OF PREAUTH
Post procedure clinical photograph,
Radiographic Image/CD
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
388Interventional
Radiology
Embolization Of Av Malformation Of Peripheral Extremity, Craniofascial
And Visceral Per Sitting
(M15W1. 34)
CT scan/ MRI Post procedure Angiographic Image
389Medical
OncologyCyclophosphamide / Methotraxate / 5flurouracil (Cmf) (M1K1.5) Biopsy/Histopatholigy report Post treatment clinical notes & Chemo sheets
390Medical
OncologyPaclitaxel (M1K1.4)
Biopsy/Histopatholigy report, Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHPost treatment clinical notes & Chemo sheets
391Medical
Oncology
Adriamycin/Cyclophosphamide
(AC) (M1K1.1)
Biopsy/Histopatholigy report, Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHPost treatment clinical notes & Chemo sheets
392Medical
Oncology
5- Flurouracil A-C (FAC) (M1K
1.2)
Biopsy/Histopatholigy report, Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHPost treatment clinical notes & Chemo sheets
393Medical
OncologyAC (AC Then T) (M1K1.3)
Biopsy/Histopatholigy report, Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHPost treatment clinical notes & Chemo sheets
394Medical
OncologyTamoxifen Tabs (M1K1.6)
Biopsy/Histopatholigy report, Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHPost treatment clinical notes & Chemo sheets
395Medical
OncologyAromatase inhibitors (M1K1.7)
Biopsy/Histopatholigy report, Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHPost treatment clinical notes & Chemo sheets
396Medical
Oncology
Bladder Cancer Weekly
Cisplastin (M1K2.1)USG, Biopsy/Histopatholigy report Post treatment clinical notes & Chemo sheets
397Medical
OncologyInduction Phase (M1K20.1)
CBC, BM Asp Biopsy, cytochemistry/ Surface
markersPost treatment clinical notes & Chemo sheets
398Medical
Oncology
Comsolidation Phase
(M1K20.2)BM Asp Biopsy Post treatment clinical notes & Chemo sheets
399Medical
OncologyMaintenance Phase (M1K20.3) CBC Post treatment clinical notes & Chemo sheets
400Medical
Oncology
Induction 1st And 2nd
Months(M1K21.1)
CBC, BM Asp Biopsy, cytochemistry/ Surface
markersPost treatment clinical notes & Chemo sheets
401Medical
Oncology
Induction 3rd, 4th, 5th
(M1K21.2)BM Asp Biopsy Post treatment clinical notes & Chemo sheets
402Medical
OncologyMaintenance Phase (M1K21.3) CBC Post treatment clinical notes & Chemo sheets
403Medical
Oncology
Palliative Chemotherapy
Unlisted Regimen (M1K22.1)Biopsy/Histopatholigy report, USG/CT Scan Post treatment clinical notes & Chemo sheets
404Medical
Oncology
Palliative And Supportive
Therapy (M1K23.1)Biopsy, USG/CT/ Blood test Post treatment clinical notes & Chemo sheets
405Medical
OncologyCisplastin/5-Fu (M1K24.1) Biopsy/Histopatholigy report Post treatment clinical notes & Chemo sheets
406Medical
OncologyXelox Along With Adjuvant Chemotherapy Of As- I(M1K25.1) CT Abdomen, Biopsy/Histopatholigy report USG/CT/Biopsy/Biochemical Investigations
407Medical
Oncology
2nd Line Iv Antibiotics And Other Supportive Therapy(Carbapenems,
Fourth Generation Cephalosporins, Piperacillin, Anti-Fungal . Azoles
Etc.,) (M1K27.2)
Clinical notes, CBC, Blood C/s / Urine C/S, Biopsy,
CXRUSG/CT/Biopsy/Biochemical Investigations
408Medical
Oncology
1st Line Iv Antibiotics And Other Supportive Therapy ( Third Generation
Cephalosporin, Aminoglycoside Etc.,) (M1K27.1)
Clinical notes, CBC, Blood C/s / Urine C/S, CXR/ CT
scan,USG/CT/Biopsy/Biochemical Investigations
409Medical
OncologyMethotraxate Vinblastin Adriamycin Cyclophosphamide (MVAC)
USG, Biopsy/Histopatholigy report Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTH
Post treatment evidence of clinical
improvements & lab investigations
410Medical
OncologyCisplastin/Etoposide (IIIB) (M1K3.1)
X-Ray/CT Scan,Biopsy/FNAC Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
411Medical
OncologyCisplastin- 5FU (M1K28. 1)
CT Scan/ USG, Biopsy Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
412Medical
Oncology5-FU Leucovorin (MCDONALD Regimen) (M1K5.1)
Endoscopy/CT Scan, Biopsy Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
413Medical
OncologyMonthly 5-FU (M1K6.1)
Endoscopy/CT Scan, Biopsy, CEA Optional
Planned CHEMOTHERAPY REGIMEN AT TIME OF
PREAUTH
Clinical photograph, Chemo charts
414Medical
Oncology5- Flurouracil-Oxaliplastin Leucovorin (Folfox) (Stage III only) (M1K6.2)
Endoscopy/CT Scan, Biopsy Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
415Medical
Oncology
Cisplastin/Adriamycin
(M1K12.1)
USG/CT Scan / Biopsy Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
416Medical
OncologyVincristin Adriamysin Dexmethasone (VAD) (M1K10.1)
Bone marrow, S. Immune electrophoresis, Bence
Jones Protiens (urine)
Planned CHEMOTHERAPY REGIMEN AT TIME OF
PREAUTH
Clinical photograph, Chemo charts
417Medical
OncologyThalidomide + Dexamethasone oral (M1K10.2)
Bone marrow, S. Immune electrophoresis, Bence
Jones Protiens (urine) Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTH
Clinical photograph, Chemo charts
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
418Medical
Oncology
Melphalan Prednisone oral
(M1K10.3)
Bone marrow, S. Immune electrophoresis, Bence
Jones Protiens (urine)
Planned CHEMOTHERAPY REGIMEN AT TIME OF
PREAUTH
Clinical photograph, Chemo charts
419Medical
OncologyZoledronic acid along with Ajuvant Chemotherapy of AS-1 (M1K10.4)
Bone marrow, S. Immune electrophoresis, Bence
Jones Protiens (urine)
Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTH
Clinical photograph, Chemo charts
420Medical
OncologySIOP/NWTS Regimen (stages I III) -permonth (M1K11.1)
Biopsy / USG/CT
Planned CHEMOTHERAPY REGIMEN AT TIME OF
PREAUTH
Clinical photograph, Chemo charts
421Medical
Oncology
Cervical Cancer Weekly
Cisplastin (M1K13.1)
Biospy, USG/CT
Planned CHEMOTHERAPY REGIMEN AT TIME OF
PREAUTH
Clinical photograph, Chemo charts
422Medical
OncologyVariable regimen (M1K14.1)Hematology - Payable maximum upto
Tumour Biospy/Bone marrow aspi / USG/CT/PET-
CT & Planned CHEMOTHERAPY REGIMEN (any
change in regimen should be informed promptly)
Clinical Photograph, Chemo Charts
423Medical
Oncology
Variable regimen (M1K15.1)X-Ray/CT Scan - Payable maximum
upto/Per month
Biospy, CT scan/PET, Plan of
CHEMOTHERAPY REGIMEN(any change in regimen
should be informed promptly)
Clinical Photograph, Chemo Charts
424Medical
Oncology
Carbo/Etoposide/Vincristin
(M1K16.1)
MRI/CT Orbit/USG orbit Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
425Medical
OncologyVariable regimen (M1K17.1)
Biopsy, CT/Skeletal study
Planned CHEMOTHERAPY REGIMEN AT TIME OF
PREAUTH(any change
in regimen should be informed
promptly)
Clinical photograph, Chemo charts
426Medical
Oncology
Vincristin- Actinomycin- Cyclophosphamide (VACTC) based chemo per
month (M1K18.1)
Biospy, CT/USG/PET-CT Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
427Medical
Oncology
Variable regimen (M1K19.1)Hematology, Biopsy - Payable maximum
upto
Biopsy, Xray/CT/PET-CT Planned
CHEMOTHERAPY REGIMEN (any change in
regimen should be informed promptly)
Clinical Photograph, Chemo Charts
428Medical
Oncology
Carboplastin / Paclitaxel
(M1K29.1)
Biopsy, USG/CT, Ca 125
Planned CHEMOTHERAPY REGIMEN AT TIME OF
PREAUTH
Clinical photograph, Chemo charts
429Medical
OncologyBleomycin-Etoposide- Cisplastin (BEP) (M1K30.1)
Biopsy, USG/CT, S.A FP/ B HCG Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
430Medical
Oncology
Weekly Methotrexate
(M1K31.1)
Biopsy , USG/CT, B HCG Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
431Medical
OncologyActinomycin (M1K31.2)
Biopsy , USG/CT, B HCG Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
432Medical
Oncology
Etoposide -Methotrexate- Actinomycin/ Cyclophospamide Avincristine
(EMA-CO) (M1K32.1)
Biopsy , USG/CT, B HCG Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
433Medical
OncologyBleomycin-Etoposide- Cisplastin (BEP) (M1K33.1)
Biopsy, USG/CT, S.A FP/ B HCG Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
434Medical
Oncology
Hormonal therpay-per month
(M1K34.1)
Biospy, USG, PSA
Planned CHEMOTHERAPY REGIMEN AT TIME OF
PREAUTH
Clinical photograph, Chemo charts
435Medical
OncologyCisplastin 5-FU (M1K4.1)
Biopsy, Endoscopy/CT scan Planned
CHEMOTHERAPY REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
436Medical
Oncology
Cisplastin / adriamycin
(M1K7.1)
Biospy, Xray/CT scan Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
437Medical
OncologyAdriamycin Bleomycin Vinblastin Dacarbazine (ABVD) (M1K8.1)
Biospy, CT scan/PET Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
438Medical
Oncology
Cyclophosphamide adriamycin
Vincristin prednisone (CHOP)
Biospy, CT scan/PET Planned CHEMOTHERAPY
REGIMEN AT TIME OF PREAUTHClinical photograph, Chemo charts
439 Nephorology
Maintenance Haemodialysis
For CRF- 1 Day Stay Per Dialysis
(M8T2.6)
RFT , S. Protein, USG Abdomen, ( At the time of
first preauthorisation)
Post treatment evidence of clinical
improvements & Sr. Creatinine photo of each
dialysis sessions mandatory for claim
440 NephorologyChronic Renal Failure 1 (CRF) -
5 Days Stay (M8T2.5)RFT, S. Protein, Sr. Electrolites, USG Abdomen
Post treatment evidence of clinical
improvements & lab investigations
441 Nephorology Rapidly Progressive Renal Failure (RPRF)10 Days (M8T2.4)RFT, S. Protein, USG Abdomen, Sr.
Electrolytes, (ANA/DsDNA/ANCA/C3 /C4 optional)
Post treatment evidence of clinical
improvements & lab investigations, Renal
Biopsy
442 NephorologyNephrotic Syndrome - 4 Days
Stay(M8T2.3)RFT, S. Protein, USG Abdomen, Sr. Electrolytes
Post treatment evidence of clinical
improvements & lab investigations, Renal
Biopsy
443 NephorologyAcute Renal Failure-(ARF) -10
Days Stay In Micu (M8T2.2)RFT, S. Protein, USG Abdomen, Sr. Electrolytes
Post treatment evidence of clinical
improvements & lab investigations
444 NeurologyImmunoglobulin Therapy -5
Days Stay(M9T3.11)
Investigation Indicative of Disease, CSF Analysis,
sr.pottassium
Post treatment evidence of
clinical improvements & lab investigations
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
445 Neurology Neuropathies (GBS) - 10 Days . Icu 20 Days - Ward Stay(M9T3.9) CSF Analysis, sr.pottassium
Post treatment evidence of
clinical improvements & lab
investigations, Nerve
Conduction Study, EMG
446 Neurology
Neuroinfections - Viral
Meningoencephalitis
(Including Herpes Encephalitis)
- Min 10 Days - Icu, 7 Days -
Ward Stay (M9T3.7)
CT/MRI Brain, CSF analysis, CSF Antibodies for HSVPost treatment evidence of clinical
improvements & lab investigations
447 Neurology
Neuroinfections - Pyogenic
Meningitis -Min 10 Days - Icu,
7 Days - Ward Stay (M9T3.6)
ADA, MRI BRAIN/CT BRAIN, CSF ANALYSIS, CELL
COUNT
Post treatment Evidence of clinical imrovement
,LAB INVESTIGATIONS
448 NeurologyIschemic Strokes-15 Days Stay
(M9T3.3)CT-Brain/ Carotid vertebral doppler
Post treatment evidence of
clinical improvements & lab investigations,
449 NeurologyHaemorrhagic Stroke/Strokes -
15 Days Stay(M9T3.2)CT-Brain/ MRI/MRV/MRA, ECG - not mandatory
Post treatment evidence of
clinical improvement & Lab investigations
450 NeurologyChronic inflammatory demyelinating polyneuropathy (CIDP) -10 Days
Stay(M9T3.1)
CSF ANALYSIS,SERUM PROTEIN
ELECTROPHORESIS, NERVE BIOPSY(optional), NCS,
EMG
Post treatment Evidence of clinical imrovement
,LAB INVESTIGATIONS
451 Neurology ADEM Or Relapse In Multiple Sclerosis 15 Days Stay(M9T3.12)MRI BRAIN/ SPINAL CORD (3 SITES) PLAIN/
CONTRAST, CSF ANALYSISCLINICAL IMPROVEMENT, LAB INVESTIGATIONS
452 NeurologyMyopathies - Acquired
(M9T3.4)
EMG, Serum alkaline phosphatase, Endocrine
evaluation, Muscle biopsy
Post treatment Evidence of clinical imrovement
,LAB INVESTIGATIONS
453 NeurologyNeuroinfections- Fungal
Meningitis (M9T3.5)CT Brain/MRI Brain, CSF analysis, cell count, ADA
Post treatment Evidence of
clinical imrovement ,LAB INVESTIGATIONS/
Blood Culture
454 Neurology Neuromuscular (Myasthaenia gravis) (M9T3.8)RNS/ CT chest/ Neostigmine test/
thyroid profile
Post treatment Evidence of
clinical imrovement ,LAB INVESTIGATIONS
455 Neurology Optic Neuritis (M9T3.10) MRI Brain and optic nerves, VEPs, CSF analysis
Post treatment Evidence of
clinical imrovement ,LAB
INVESTIGATIONS
456 NeurosurgeryEndoscopic Third
Ventriculostomy (S10I1.8)CT/MRI Clinical photo, Notes/CT/MRI
457 NeurosurgeryIntra-Cerebral Hematoma
Evacuation (S10I1.7)CT/MRI
Clinical photo,
Notes/CT/MRI post
op suture line photo mandatory for claim
458 Neurosurgery De-Compressive Craniotomy(Non Traumatic) (S10I1.6) CT/MRI
Clinical
photo,Notes/CT/Xray/MRI post op suture line
photo mandatory for claim
459 Neurosurgery Evacuation Of Brain Abscess - Burr Hole (S10I1.3) CT/MRI
Post procedure clinical
photograph/CT/MRI
post op suture line photo mandatory for claim
460 NeurosurgeryCraniotomy And Evacuation Of
Hematoma Subdural (S10I1.1)CT/MRI
Post procedure clinical
photograph/CT/MRI
post op suture line photo mandatory for claim
461 Neurosurgery
Craniotomy And Evacuation Of
Hematoma Extradural
(S10I1.2)
CT/MRI
Post procedure clinical
photograph/CT/MRI
post op suture line photo mandatory for claim
462 Neurosurgery Excision of Lobe (Frontal, Temporal, Cerebellum etc.) (S10I1.4) CT/MRI Clinical photograph/ CT/MRI, HPE
463 Neurosurgery Parasagittal tumour (S10I2.1) CT/MRIClinical photograph/
CT/MRI, HPE
464 Neurosurgery Basal Brain Tumour (S10I2.2) CT/MRIClinical photograph/
CT/MRI, HPE
465 Neurosurgery Brain Stem Tumour (S10I2.3) CT/MRIClinical photograph/
CT/MRI, HPE
466 Neurosurgery Other Procedures (S10I3.1) CT/MRIClinical photograph/
CT/MRI, HPE
467 NeurosurgeryTemporal Lobectomy
(S10I10.1)MRI, VIDEO EEG, PSYCHOLOGIC ASSESSMENT
Clinical photograph/
CT/MRI, HPE post op
suture line photo mandatory for claim
468 Neurosurgery Lesionectomy type 1 (S10I10.2) MRI, VIDEO EEG, PSYCHOLOGIC ASSESSMENT Clinical photograph/ CT/MRI, HPE
469 Neurosurgery Lesionectomy type 2 (S10I10.3) MRI, VIDEO EEG, PSYCHOLOGIC ASSESSMENT Clinical photograph/ CT/MRI, HPE
470 NeurosurgeryTemporal lobectomy plus
Depth Electrodes (S10I10.4)MRI, VIDEO EEG, PSYCHOLOGIC ASSESSMENT Clinical photograph/ CT/MRI/Xray, HPE
471 NeurosurgeryMicro Vascular Decompression
(S10I11.2)CT/MRI Post procedure clinical photograph/CT/MRI
472 NeurosurgeryRadiofrequency Ablation
(S10I11.1)CT/MRI
Post procedure clinical
photograph/CT/MRI
473 NeurosurgeryManagement of Aneurysm
Cost Of Each Coil (S10I12.2)CT/MRI/ DSA
Post procedure clinical
photograph/CT/MRI/Angio
474 Neurosurgery Embolization (S10I12.1) CT/MRI/ DSAPost procedure clinical
photograph/CT/MRI/Angio
475 NeurosurgerySurgery on cord tumours
(S10I5.1)CT/MRI
Clinical photograph/
CT/MRI, HPE
476 NeurosurgeryExternal Ventricular Drainage
(EVD) (S10I2.13)CT/ MRI Clinical photograph / Xray/ CT/ MRI
477 Neurosurgery Aneurysm Clipping (S10I2.12) CT/MRI /DSAClinical photograph/ X-
Ray/CT/MRI/angio
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
478 NeurosurgeryExcision Of Brain Abscess
(S10I2.11)CT/MRI
Clinical photograph/
HPE/Pus c/s/CT/MRI
479 Neurosurgery Atrial shunt (S10I3.10) CT/MRIClinical photograph / Xray/
CT/ MRI
480 Neurosurgery Peritoneal shunt (S10I3.9) CT/MRIClinical photograph / Xray/
CT/ MRI
481 Neurosurgery
Ventriculolateral /
Ventriculoperitoneal Shunt
(S10I3.3)
CT/MRI Clinical photograph / Xray/ CT/ MRI
482 NeurosurgeryTwist Drill craniotomy
(S10I3.4)CT/ MRI Clinical photograph / Xray/ CT/ MRI
483 Neurosurgery Subdural Tapping (S10I3.5) CT/ MRIClinical photograph / Xray/
CT/ MRI
484 Neurosurgery Ventricular Tapping (S10I3.6) CT/ MRIClinical photograph / Xray/
CT/ MRI
485 Neurosurgery Abscess tapping (S10I3.7) CT/ MRIClinical photograph / Xray/
CT/ MRI/ Pus c/s
486 NeurosurgeryVascular malformations
(S10I3.8)MRI/CT/Angio Clinical photograph/MRI/CT/Angio
487 NeurosurgeryVentriculoatrial Shunt
(S10I2.10)CT/MRI
Post procedure clinical
photograph/CT/Xray
488 Neurosurgery Meningocele Excision (S10I2.9) CT/MRIPost procedure clinical
photograph/CT/Xray
489 Neurosurgery Cranioplasty (S10I2.8) CT/MRIPost procedure clinical
photograph/CT/Xray
490 Neurosurgery C.S.F. Rhinorrhoea (S10I2.7) CT/MRIPost procedure clinical
photograph/CT/Xray
491 Neurosurgery Meningomylocele (S10I2.6) CT/MRIPost procedure clinical
photograph/CT/MRI
492 NeurosurgeryMeningoencephalocele
(S10I2.5)CT/MRI
Post procedure clinical
photograph/CT/MRI
493 Neurosurgery C P Angle (S10I2.4) CT/MRIClinical photograph/
CT/MRI, HPE
494 NeurosurgeryExcision Of Brain Tumours
Subtentorial (S10I3.2)CT/MRI Clinical photograph/ CT/MRI, HPE
495 NeurosurgeryEndoscopy procedures
(S10I1.5)CT/MRI Endoscopy picture/CT/MRI
496 Neurosurgery C.V. Junction fusion (S10I6.5) MRI/ CT, X-RAY CERVICAL SPINEPost procedure clinical
photograph /X-RAY/CT/MRI
497 Neurosurgery Combined trans oral surgery and CV Junction fusion (S10I6.4) MRI/ CT, X-RAY CERVICAL SPINEPost procedure clinical photograph /X-
RAY/CT/MRI
498 Neurosurgery Trans oral surgery (S10I6.3) CT/MRIClinical photograph/
CT/MRI, HPE
499 NeurosurgeryTrans sphenoidal surgery
(S10I6.2)CT/MRI
Clinical photograph/
CT/MRI, HPE
500 NeurosurgeryStereotactic procedures
(S10I6.1)CT/MRI Clinical photograph/ CT/MRI, HPE
501 NeurosurgerySpinal Fusion Procedure
(S10I5.12)MRI/ CT
Post procedure clinical
photograph /Xray/CT/MRI, Bar code sticker if
allograft
502 Neurosurgery Discectomy (S10I5.11) MRI/ CTPost procedure clinical
photograph /X-RAY/CT/MRI
503 Neurosurgery Laminectomy (S10I5.10) MRI/ CTPost procedure clinical
photograph /X-RAY/CT/MRI
504 NeurosurgeryAnterolateral Decompression
(S10I5.9)MRI/ CT
Post procedure clinical photograph /X-
RAY/CT/MRI
505 NeurosurgeryAnterior Cervical Spine Surgery
With Fusion (S10I5.8)MRI/ CT, X-RAY CERVICAL SPINE
Post procedure clinical
photograph /Xray/ CT/MRI Bar code sticker if
allograft
506 NeurosurgeryAnterior Cervical Spine Surgery
With Fusion (S10I5.8)MRI/ CT
Post procedure clinical photograph /X-
RAY/CT/MRI
507 NeurosurgeryAnterior Cervical Discectomy
(S10I5.7)MRI/ CT
Post procedure clinical photograph /X-
RAY/CT/MRI
508 NeurosurgeryExcision Of Cervical
Intervertebral Discs (S10I5.5)MRI/ CT
Post procedure clinical photograph /X-
RAY/CT/MRI
509 NeurosurgerySpina Bifida Surgery Major
(S10I5.3)MRI/ CT
Post procedure clinical
photograph /X-RAY/CT/MRI
510 NeurosurgerySpina Bifida Surgery Minor
(S10I5.4)MRI/ CT
Post procedure clinical
photograph /X-RAY/CT/MRI
511 NeurosurgerySpinal Intramedullary Tumours
(S10I5.2)MRI/ CT Clinical photograph/Xray/ CT/MRI, HPE
512 NeurosurgerySpinal Fixation Rods And
Plates, Artificial Discs (S10I8.4)MRI/ CT X ray/CT/MRI
513 NeurosurgeryDiscectomy With Implants
(S10I8.2)MRI/ CT
X- RAY/CT/MRI, bar code
stickers
514 NeurosurgeryAnterior Discectomy & Bone
Grafting(S10I8.1)MRI/ CT X ray/CT/MRI
515 NeurosurgeryCorpectomy for Spinal Fixation
(S10I8.3)MRI/ CT X ray/CT/MRI
516 Neurosurgery Syringomyelia (S10I8.5) MRI/ CTPost procedure clinical
photograph/CT/MRI
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
517 NeurosurgeryRepair of Brachial plexus injury
(S10I9.1)NCV/EMG/CT/MRI Clinical photograph/EMG/NCV
518 NeurosurgeryCervical Sympathectomy
(S10I9.2)EMG,Nerve conduction CT/MRI Post procedure clinical photograph
519 NeurosurgeryLumbar sympathectomy
(S10I9.3)EMG,Nerve conduction /CT/MRI / Color doppler Clinical photograph/HPE
520 NeurosurgeryPeripheral Nerve Injury
Repair(S10I9.5)EMG, NERVE CONDUCTION Post procedure clinical photograph
521 Neurosurgery Proptosis (S10I9.6) MRI/ CTPost procedure clinical
photograph/CT/MRI
522 NeurosurgeryDecompression/ Excision Of
Optic Nerve Lesions (S10I9.4)MRI/ CT Post procedure clinical photograph/CT/MRI
523Opthalmology
SurgeryPediatric Cataract Surgery - Phacoemulsification . Iol (S3B10.2) B.SCAN, Post procedure clinical photograph
524Opthalmology
Surgery
Penetrating Keratoplasty
(S3B5.5)B.SCAN, Clincial Photograph Post procedure clinical photograph
525Opthalmology
SurgeryLamellar Keratoplasty (S3B5.2) B.SCAN Post procedure clinical photograph
526Opthalmology
Surgery
Removal Of Silicon Oil Or Gas
(S3B6.5)
B.SCAN, FUNDUS PHOTOGRAPH/
Sketch
FUNDUS PHOTOGRAPH/
Sketch
527Opthalmology
Surgery
Vitrectomy Plus Silicon Oil Or
Gas.(S3B6.6)B.SCAN, FUNDUS PHOTOGRAPH/ Sketch FUNDUS PHOTOGRAPH/ Sketch
528Opthalmology
SurgeryVitrectomy - Membrane Peeling Endolaser , Silicon Oil Or Gas(S3B6.4) B.SCAN, FUNDUS PHOTOGRAPH/ Sketch FUNDUS PHOTOGRAPH/ Sketch
529Opthalmology
Surgery
Vitrectomy + Membrane
Peeling+ Endolaser(S3B6.2)B.SCAN, FUNDUS PHOTOGRAPH/ Sketch FUNDUS PHOTOGRAPH/ Sketch
530Opthalmology
SurgeryVitrectomy(S3B6.1)
B.SCAN,
Fundus photograph is mandatory at time of
preauth
Post procedure clinical
photograph Fundus photograph is mandatory
at time of claims
531Opthalmology
Surgery
Enucleation With Orbital
Implant(S3B7.4)CLINICAL PHOTOGRAPH, ORBIT Post procedure clinical photograph
532Opthalmology
Surgery
Lid Reconstruction Surgery
(S3B9.1)CLINICAL PHOTOGRAPH
Post procedure clinical
photograph
533Opthalmology
SurgeryCorneal patch graft (S3B5.3) CLINICAL PHOTOGRAPH
Post procedure clinical
photograph
534Opthalmology
SurgeryScleral patch graft (S3B5.4) CLINICAL PHOTOGRAPH
Post procedure clinical
photograph
535Opthalmology
Surgery
Therapeutic Penetrating
Keratoplasty (S3B5.1)B.SCAN, Clincial Photograph Post procedure clinical photograph
536Opthalmology
SurgeryDouble Z plasty (S3B5.6) CLINICAL PHOTOGRAPH
Post procedure clinical
photograph
537Opthalmology
Surgery
Amniotic membrane graft
(S3B5.7)CLINICAL PHOTOGRAPH
Post procedure clinical
photograph
538Opthalmology
SurgeryScleral buckle for Retinal detachment (S3B11.1) B.SCAN, FUNDUS PHOTOGRAPH/ Sketch FUNDUS PHOTOGRAPH/ Sketch
539Opthalmology
SurgeryDermis fat graft (S3B7.2) CLINICAL PHOTOGRAPH
Post procedure clinical
photograph
540Opthalmology
SurgeryOrbitotomy (S3B7.3) CT Scan
Post procedure clinical
photograph
541Opthalmology
Surgery
Rectus muscle surgery single
(S3B8.1)CLINICAL PHOTOGRAPH Post procedure clinical photograph
542Opthalmology
Surgery
Rectus muscle surgery
Two/Three (S3B8.2)CLINICAL PHOTOGRAPH Post procedure clinical photograph
543Opthalmology
SurgeryOblique muscle (S3B8.3) CLINICAL PHOTOGRAPH
Post procedure clinical
photograph
544Opthalmology
SurgeryPhotocoagulation for Retinopathy of prematurity (S3B10.1)
Fundus Fluorescence Angiography or Optical
Coherence Tomography , Fundus
Photograph/Sketch
Post procedure evidence of Clinical Photograph
showing procedure
545Opthalmology
Surgery
Glaucoma filtering surgery for paediatric Glaucoma
(S3B10.3)USG , OCT, Fundus Photograph/ Sketch
Post procedure evidence of
Clinical Photograph
546Opthalmology
Surgery
Socket reconstruction
(S3B7.1)CLINICAL PHOTOGRAPH Post procedure clinical photograph
547Opthalmology
Surgery
Monthly Intravitreal Anti - VEGF for macular degeneration - per
injection (maximum - 6) (S3B6.3)B.Scan , Fundus Photograph/ Sketch, OCT
Post procedure evidence of Fundus photo/
Sketch / optical coherence tomography.
548Opthalmology
SurgeryPhotocoagulation for diabetic retinopathy per sitting (S3B11.2) B.Scan , Fundus Photograph/Sketch
Post procedure evidence of
Fundus photograph/Sketch
549Orthopedic Surgery
and Procedures
Ilizarov Ring Fixator
Application.(S5D1.5)
X ray
mandatory requireed clinical photo of part for
pre auth
post procedure x ray
mandatory requireed clinical photo of part for
claim
550Orthopedic Surgery
and ProceduresReduction Of Compound Fractures & External Fixation(S5D1.4)
X ray
mandatory requireed clinical
photo of part for pre auth
post procedure x ray
mandatory requireed clinical photo of part for
claim
551Orthopedic Surgery
and Procedures
Open Reduction & Internal
Fixation Of Fingers & Toes
@Rs5000 Each Up To
Maximum Of Rs 15000(S5D1.3)
X- RAY post procedure x ray
552Orthopedic Surgery
and ProceduresExcision Or Other Operations For Scaphoid Fractures(S5D1.2) X- RAY post procedure x ray
553
Orthopedic
Surgery and
Procedures
Bone Grafting As Exclusive
Procedure(S5D1.1)X ray post procedure x ray
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
554Orthopedic Surgery
and Procedures
Amputations - Hind Quarter
And Hemipelvectomy (S5D2.3)x ray post procedure x ray / Clinical photgraph
555
Orthopedic
Surgery and
Procedures
Amputations - Forequarter
(S5D2.2)X- RAY post procedure x ray / Clinical photgraph
556
Orthopedic
Surgery and
Procedures
Open Reduction Of
Dislocations - Deep(S5D2.1)x ray post procedure x ray
557Orthopedic Surgery
and ProceduresSoft Tissue Reconstruction Procedures For Joints/ Osteotomy (S5D2.9)
clinical photo, X-ray mandatory requireed clinical
photo of part for pre auth
post procedure x ray /
Clinical photgraph mandatory requireed clinical
photo of part for pre auth and claim
558Orthopedic Surgery
and ProceduresAvascular Necrosis Of Femoral Head (Core Decompression)(S5D2.8) x ray, MRI post procedure x ray
559
Orthopedic
Surgery and
Procedures
Arthroscopy - Acl Repair
(S5D2.7)MRI/ Xray Arthoscopic video intra op, Xray
560Orthopedic Surgery
and Procedures
Arthroscopy. Operative
Meniscectomy (S5D2.6)MRI/ Xray Arthoscopic video intra op
561
Orthopedic
Surgery and
Procedures
Arthroscopy - Diagnostic
(S5D2.5)MRI/ Xray Arthoscopic video intra op
562
Orthopedic
Surgery and
Procedures
Arthrodesis Of - Major Joints
(S5D2.4)X- RAY X- RAY
563
Orthopedic
Surgery and
Procedures
Spinal Ostectomy And Internal
Fixations(S5D2.12)MRI/ Xray post procedure x ray
564Orthopedic Surgery
and Procedures
Anterolateral Clearance For
Tuberculosis(S5D2.10)MRI/ Xray BIOPSY, post procedure x ray
565Orthopedic Surgery
and Procedures
Operations For Brachial Plexus
& Cervical Rib (S5D2.15)Xray,NCS/EMG / MRI
Post procedure clinical photograph X-ray
mandatory during claims
566
Orthopedic
Surgery and
Procedures
Nerve Repair With Grafting
(S5D2.13)CLINICAL PHOTOGRAPH, NCS Post procedure clinical photograph
567Orthopedic Surgery
and ProceduresExcision Of Bone Tumours. Deep With Re-Construction With Conventional Prosthesis(S5D6.1)MRI/ Xray
Post procedure clinical photograph, post
procedure x ray, Biopsy
568
Orthopedic
Surgery and
Procedures
CTEV Neglected. JESS Fixator
(S5D1.6)Clinical Photograph
Post procedure evidence of
Clinical photograph, X-Ray
569
Orthopedic
Surgery and
Procedures
Neurolysis/Nerve Suture
(S5D2.14)Clinical Photograph
Post procedure evidence of
Clinical Photograph
570
Orthopedic
Surgery and
Procedures
Costo Transversectomy
(S5D2.11)MRI
Post procedure evidence of
Post op X-Ray
571 Pediatric Surgery Hirschsprung Disease Stage 2 (S8G1.8) CLINICAL PHOTOGRAPH/Imaging/ Biopsy BIOPSY, Post procedure scar photograph
572 Pediatric SurgeryAnorectal Malformations Stage
2(S8G1.6)
Clinical Photograph, Distal Cologram, USG
Abdomen, Xray Lumbosacral spine (inverted
position)
Post procedure Scar photograph operative/
procedure notes
573 Pediatric SurgeryAnorectal Malformations Stage
1(S8G1.5)
CLINICAL PHOTOGRAPH, Xray
Abdomen(Inverted position), Clinical NotesPost procedure Scar photograph
574 Pediatric SurgeryBiliary Atresis & Choledocal
Cyst(S8G1.4)CLINICAL PHOTOGRAPH, LFT, USG/ Imaging
Post procedure clinical photograph USG, LFT
GGT is mandatory at time of claims
575 Pediatric Surgery Intestinal Atresias & Obstructions(S8G1.3) X- RAY, Imaging
Post procedure clinical
photograph USG/imaging is mandatory at
time of claims
576 Pediatric Surgery Diaphragmatic Hernia (S8G1.2) Chest X-ray AP/Lat, USG/CT scanChest xray AP/Lat Post
procedure clinical photograph
577 Pediatric Surgery Oesophageal Atresia (S8G1.1) X- RAY, TOF test req at time of
preauth. Post Procedure Clinical Photograph,
578 Pediatric SurgeryHypospadius Single Stage
(S8G2.6)CLINICAL PHOTOGRAPH
Post procedure clinical
photograph
579 Pediatric Surgery Hypospadius Stage-1 (S8G2.15) CLINICAL PHOTOGRAPHPost procedure clinical
photograph
580 Pediatric SurgeryLymphangioma Excision
(S8G2.18)Neuro USG + CT Post Procedure Photo
581 Pediatric SurgeryHemangioma Excision
(S8G2.17)Neuro USG + CT Post Procedure Photo
582 Pediatric Surgery Hamartoma Excision (S8G2.16) CT / Clinical PhotographPost Procedure Photo,
Biopsy is mandatory at time of claims
583 Pediatric Surgery TM joint ankylosis (S8G2.14) CLINICAL PHOTOGRAPH / Xray Post Procedure Photo
584 Pediatric Surgery Microtia/ Anotia (S8G2.13) CLINICAL PHOTOGRAPH Post Procedure Photo
585 Pediatric Surgery Syndactyly of hand for each hand (S8G2.12) CLINICAL PHOTOGRAPH Post Procedure Photo
586 Pediatric SurgeryVelo-Pharyngial Incompetence
(S8G2.11)Endoscopy, Contrast Study Post Procedure Photo
587 Pediatric Surgery Cleft Palate (S8G2.10) CLINICAL PHOTOGRAPH Post Procedure Photo
588 Pediatric Surgery Cleft Lip (S8G2.9) CLINICAL PHOTOGRAPH Post Procedure Photo
589 Pediatric Surgery Pediatric Tumours (S8G2.8)Imaging / BIOPSY, tumour markers at time for
preauth
Post procedure clinical photograph Biopsy
should be mandatory for claims
590 Pediatric Surgery Hypospadius Stage- 2 (S8G2.7) CLINICAL PHOTOGRAPHPost procedure clinical
photograph
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
591 Pediatric SurgeryPosterior Urethral Valves
(S8G2.5)MCU / USG
clinical notes, clinical photo
with catheter
592 Pediatric Surgery Encephalocele (S8G3.4) MRI/ CT/ NEURO USGPost procedure clinical
photograph
593 Pediatric Surgery Neuroblastoma (S8G3.1) Imaging / biopsyUSG, BIOPSY,Post
procedure clinical photograph
594 Pediatric SurgeryCongenital Dermal Sinus
(S8G3.2)Neuro USG /CT Contrast study
Post Procedure Clinical
Photograph, Biopsy
595 Pediatric SurgeryCystic Lesions of the Neck
(S8G3.3)USG, MRI /CT, Clinical Photograph
Post Procedure Clinical
Photograph, histopath
596 Pediatric SurgerySinuses & Fistula of the Neck
(S8G3.5)
USG/CT, contrast study, Clinical
Photograph
Post Procedure Clinical
Photograph, histopath
597 Pediatric SurgeryBronchoscopy Foreign Body
Removal(S8G4.1)Imaging/ ENDOSCOPIC VIDEO
Xray / clinical photograph,
/Scopy Photo/Video ensure bronchoscopy is
done only once
598 Pediatric Surgery Paediatric Esophageal Obstructions- Surgical Correction (S8G4.2) Contrast UGI Clinical Photograph
599 Pediatric SurgeryPaediatric Esophageal
Substitutions (S8G4.3)Contrast study Clinical Photograph
600 Pediatric SurgeryThoracoscopic Cysts Excision
(S8G4.4)USG / CT Post procedure clinical photograph, Biopsy
601 Pediatric SurgeryThoracoscopic Decortication
(S8G4.5)USG / CT Post procedure clinical photograph, Biopsy
602 Pediatric Surgery Thoracic Duplications (S8G4.6) Xray, CT Post procedure clinical photograph, Biopsy
603 Pediatric Surgery Thoracic Wall defects - correction (S8G4.7) Xray, CT Post procedure clinical photograph
604 Pediatric SurgeryGastric outlet Obstruction
(S8G5.1)Contrast USG, Xray Post procedure clinical photograph
605 Pediatric Surgery Laparoscopic pull through surgeries for HD (S8G5.2) USG/Biopsy, Clinical PhotographPost procedure clinical photograph, Biopsy,
Video
606 Pediatric SurgeryPaediatric Splenectomy (Non
Traumatic) (S8G5.3)USG, Heamogram, Post procedure clinical photograph, Biopsy, USG
607 Pediatric SurgerySurgeries on adrenal gland in
Children (S8G5.4)CT, Hormone Assays Post procedure clinical photograph, Biopsy, USG
608 Pediatric Surgery Hydatid cysts in Paediatric patient (S8G5.6) CT, USG Post procedure clinical photograph, Biopsy, USG
609 Pediatric Surgery Intestinal Polyposis Surgical correction (S8G5.7) USG/CT contrast studyPost Procedure Clinical
Photograph, histopath
610 Pediatric SurgeryLaparoscopic
Choleycystectomy (S8G5.11)USG, Clinical photo
Post procedure clinical
photograph, histopath, Video
611 Pediatric Surgery Laparoscopic pull through for Ano Rectal Anomalies (S8G5.12) CLINICAL PHOTOGRAPH, USG Post procedure clinical photograph,VIDEO, USG
612 Pediatric SurgeryLaparoscopic Appendectomy
(S8G5.10)CLINICAL PHOTOGRAPH, USG
Post procedure clinical
photograph,VIDEO
USG is mandatory during claims
613 Pediatric SurgeryPaediatric Acute Intestinal
Obstruction (S8G5.9)X-ray, CT/ USG
Post procedure clinical
photograph,VIDEO
USG is mandatory during claims
614 Pediatric Surgery Intussusception(S8G5.8) CT/ USGPost procedure clinical
photograph, USG
615 Pediatric Surgery Torsion Testis(S8G6.5) clinical photo and colour doppler Clinical photo, Notes
616 Pediatric Surgery Hirschsprung Disease Stage 1 (S8G1.7) CLINICAL PHOTOGRAPH/Imaging/ Biopsy BIOPSY, Post procedure scar photograph
617 Pediatric SurgeryCongenital hydronephrosis
(S8G2.1)USG / Renogram
Post procedure evidence of
Clinical Photograph
618 Pediatric SurgeryUreteric reimplantations
(S8G2.2)Clinical Photograph/USG
Post procedure evidence of
Clinical Photograph
X-ray with Dj Stent for claim
619 Pediatric SurgeryExtrophy bladder Stage 1
(S8G2.3)
Clinical Photograph/USG, Xray
Pelvis
Post procedure evidence of
Clinical Photograph
620 Pediatric SurgeryExtrophy bladder Stage 2
(S8G2.4)
Clinical Photograph/USG, Xray
Pelvis
Post procedure evidence of
Clinical Photograph
621 Pediatric SurgeryGastro Esophageal Reflux
Correction (S8G5.5)Endoscopy, CT Scan / Contrast
Post procedure evidence of
Clinical Photograph
622 Pediatric Surgery Laparoscopic Varicocele ligation (S8G6.7)USG,/ Color Doppler Clinical
Photograph
Post procedure evidence of
Clinical
Photograph,USG,Video
623 Pediatric SurgeryLaparoscopic Orchidopexy
(S8G6.6)USG,Clinical Photograph
Clinical
Photograph,USG,Video
624 Pediatric Surgery Undescended Testis (S8G6.4) USG, Clinical PhotographPost procedure clinical
photograph
625 Pediatric Surgery Nephrectomy (S8G6.1) USG / CT Clnical PhotographPost procedure clinical
photograph, USG, Biopsy
626 Pediatric SurgeryEpispadiasis- Correction
(S8G6.2)CLINICAL PHOTOGRAPH Post Procedure Photo
627 Pediatric SurgeryScrotal transposition repair
(S8G6.3)CLINICAL PHOTOGRAPH Post Procedure Photo
628Pediatrics Medical
Management
Term Baby With Culture Positive Sepsis- Non Ventilated
Hyperbilirubinemia (M6S1.1)BLOOD CULTURE/ CBC , CRP, SERUM BILIRUBIN
Post procedure Evidence of clinical imrovement
AND LAB INVESTIGATIONS,
(Blood Culture/CRP/CBC)
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
629Pediatrics Medical
Management
Term Baby, Fulminant Culture Positive Sepsis, Septic Shock, Ventilated,
Hyperbilirubinemia Renal Failure (M6S1.10)
BLOOD CULTURE / CBC, CRP, RFT, SERUM
BILIRUBIN, ABG
APGAR Score to be mandate at time of admission
Post procedure Evidence of
clinical imrovement ,LAB
INVESTIGATIONS (Blood Culture/CRP/CBC/RFT)
USG ABDOMEN IS REQUIRED IN CLAIMS WHICH
WAS THERE PREVIOUSLY
630Pediatrics Medical
Management
Term baby with persistent pulmonary hypertension Ventilation-HFO
Hyperbilirubinemia Clinical sepsis (M6S1.4)
Xray chest, ABG, Sr. Bilirubin,
2decho APGAR Score to be
mandate at time of admission
post treatment evidence of clinical
improvement and lab investigations, Xray chest,
ABG, Sr. Bilirubin
631Pediatrics Medical
Management
33 To 34 Weeks Preterm Baby Severe Hyaline Membrane Disease
Clinical Sepsis Bubble CPAP Hyperbilirubinemia (M6S1.11)
ABG(optional), X- RAY CHEST, SERUM BILIRUBIN,
CRP, CBC 2d echo mandatory for pre auth
APGAR Score to be mandate at time of admission
Post procedure Evidence of clinical imrovement
, Xray chest, / ABG
632Pediatrics Medical
Management
33 To 34 Weeks Preterm Baby Severe Hyaline Membrane Disease With
Clinical Sepsis, Mechanical Ventilation Hyperbilirubinemia (M6S1.12)
ABG, X- RAY CHEST, SERUM BILIRUBIN, CBC / CRP
, Photo with ventilatory care APGAR Score to be
mandate at time of admission
Post procedure Evidence of clinical imrovement
, Xray chest, / ABG
633Pediatrics Medical
Management
35 To 36 Weeks Preterm Mild Hyaline Membrane Disease Culture
Positive Sepsis Nonventilated Hyperbilirubinemia ( )
BLOOD CULTURE/ CRP/ CBC, X- RAY CHEST,
SERUM BILIRUBIN APGAR Score to be mandate at
time of admission
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS (CBC, Sr bilirubin)
634Pediatrics Medical
Management
33 To 34 Weeks Preterm Mild Hyaline Membrane Disease Culture
Positive Sepsis – Nonventilated Hyperbilirubinemia (M6S1.14)
CBC, CRP/ BLOOD CULTURE, X- RAY CHEST, SERUM
BILIRUBIN APGAR Score to be mandate at time
of admission
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS (CBC, Sr bilirubin)
635Pediatrics Medical
Management
33 To 34 Weeks Preterm Severe Hyaline Membrane Disease Culture
Positive Sepsis Mechanical Ventilation/
Bubble Cpap
Hyperbilirubinemia ()
ABG, X- RAY CHEST, SERUM BILIRUBIN, CBC,
CRP/,BLOOD CULTURE APGAR Score to be
mandate at time of admission
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS (CBC, Xray chest /ABG)
636Pediatrics Medical
Management
30 to 32 weeks preterm Severe Hyaline membrane disease Clinical
sepsis Patent ductus arteriosus - Medical management Mechanical
ventilation Hyperbilirubinemia (M6S1.2)
2D ECHO , Blood culture / CRP, CBC ABG, Sr
Bilirubin, Xray chest
APGAR Score to be mandate at
time of admission
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS (CBC, Xray chest /ABG)
637Pediatrics Medical
Management
30 To 32 Weeks Preterm Severe Hyaline Membrane Disease Clinical/
Culture Positive Sepsis Mechanical Ventilation Hyperbilirubinemia
(M6S1.16)
ABG, X- RAY CHEST, SERUM BILIRUBIN, CBC,
CRP/BLOOD CULTURE, Clinical photo wih
ventilatory care
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS (CBC,
Xray chest /ABG)
638Pediatrics Medical
Management
<30 Weeks Preterm Severe Hyaline Membrane Disease Clinical/ Culture
Positive Sepsis Patent ductus arteriosus - Medical management
Mechanical Ventilation Hyperbilirubinemia (M6S1.3)
2D ECHO, Blood culture /CRP, CBC, ABG, Xray
chest, Sr Bilirubin
APGAR Score to be mandate at time of admission
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS (CBC, Xray chest /ABG)
639Pediatrics Medical
Management
<30 Weeks Preterm Severe Hyaline Membrane Disease Clinical/ Culture
Positive Sepsis Mechanical Ventilation Hyperbilirubinemia (M6S1.17)
ABG, X- RAY CHEST, SERUM BILIRUBIN, CBC,
CRP/BLOOD CULTURE APGAR Score to be
mandate at time of admission
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS (CBC,
Xray chest /ABG)
640Pediatrics Medical
Management
Term Baby With Severe Perinatal Asphyxia - Non Ventilated Clinical
Sepsis Hyperbilirubinemia (M6S1.5)
CBC, CRP/ BLOOD CULTURE, Sr Bilirubin APGAR
Score to be mandate at time of admission
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS, NEUROSONOGRAM/CT-
SCAN/ MRI
641Pediatrics Medical
Management
Term Baby With Severe Perinatal Asphyxia - Ventilated Clinical Sepsis
Hyperbilirubinemia (M6S1.6)
CBC, CRP/ BLOOD CULTURE, , ABG
,X- RAY CHEST, Sr Bilirubin APGAR Score to be
mandate at time of admission
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS, NEUROSONOGRAM/CT-
SCAN/ MRI
642Pediatrics Medical
ManagementTerm Baby Severe Hyperbilirubinemia Clinical Sepsis (M6S1.7)
CBC / CRP, SERUM BILIRUBIN APGAR Score to be
mandate at time of admission
Post procedure Evidence of
clinical imrovement ,LAB INVESTIGATIONS,( CBC
Sr Bilirubin)
Blood culture is mandatory at time of claims
643Pediatrics Medical
Management
Term Baby With Seizures
Ventilated (M6S1.8)
Blood sugar, Calcium, Electrolytes, CSF ANALYSIS,
ABG APGAR Score to be mandate at time of
admission
Post procedure Evidence of
clinical imrovement AND
LAB INVESTIGATIONS NEUROSONOGRAM/CT-
SCAN/MRI)
644Pediatrics Medical
Management
Necrotising enterocolitis, Clinical sepsis Non ventilated
Hyperbilirubinemia (M6S1.9)
CBC, CRP/Blood culture, Xray
Abdomen ultrasound optional
stool exam and usg mandatory for pre auth
post treatment evidence of clinical
improvement , Xray abdomen, CBC, CRP
645Pediatrics Medical
Management
33 to 34 weeks preterm Severe Hyaline Membrane disease
Clinical/Culture positive sepsis Patent ductus arteriosus- Medical
management Mechanical ventilation Hyperbilirubinemia (M6S1.18)
2D ECHO , blood culture/ CRP,CBC, ABG, X-Ray
chest, Serum bilirubin APGAR Score to be
mandate at time of admission
Post procedure Evidence of clinical imrovement
,LAB INVESTIGATIONS (CBC, Xray chest /ABG)
646Pediatrics Medical
ManagementAcute Broncho/ Lobarpneumonia With Empyema/ Pleural Effusion (M6S10.1)X- RAY, CBC, Fluid Analysis X- RAY CHEST
647Pediatrics Medical
ManagementAcute Broncho/ Lobarpneumonia With Pyo Pneumothorax 14 Days (M6S11.1)
BLOOD CULTURE/ CBC/CRP, X- RAY, PUS
CULTURE/ Gram stainX- RAY CHEST
648Pediatrics Medical
Management
Congenital Heart Disease With
Congestive Cardiac Failure - 7
Days (M6S11.2)
2D ECHO, X- RAY chest, ECG CBC, sr electrolyte
requireed for pre auth
Post Procedure evidence of Post procedure
Evidence of clinical imrovement 2D ECHO, X-
RAY CHEST
649
Pediatrics
Medical
Management
Viral Myocarditis 7 Days Stay
(M6S11.4)2D ECHO, X- RAY, ECG 2D ECHO, X- RAY CHEST, ECG
650Pediatrics Medical
Management
Steroid Resistant Nephrotic Syndrome Complicated Or Resistant - 2
Weeks Stay (M6S12.1)
URINE EXAM, RENAL BIOPSY SOS RFT'S
MANDATORY AT THE TIME OF PREAUTH.
Post procedure Evidence of clinical imrovement
AND LAB INVESTIGATIONS( Urine Albumin, HPE
if biopsy done)
651Pediatrics Medical
ManagementUrinary Tract Infection With Complications Like Pyelonephritis And Renal Failure - 10 Days Stay (M6S12.2)
Urine R/M / URINE FOR CULTURE AND
SENSITIVITY/ USG, BUN, Sr. Creat
Post procedure Evidence of clinical imrovement
AND Urine culture/ UrineR/M / USG
652Pediatrics Medical
Management
Acute Renal Failure 10 Days
Stay (M6S12.3)
RFT, ELECTROLYTES (optional)
ELECTROLYTES,C1,C3 MANDATORY AT PREAUTH,
Post procedure Evidence of clinical imrovement
AND LAB INVESTIGATIONS (RFT)
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
653
Pediatrics
Medical
Management
Acute Renal Failure With
Dialysis - 10 Days Stay
(M6S12.4)
RFT, Uric acid / SERUM ELECTROLYTES(optional)
Post procedure Evidence of
clinical imrovement AND LAB INVESTIGATIONS
(RFT)
654Pediatrics Medical
ManagementThalassemia Major Requiring Chelation Therapy - 7 Days Stay (M6S13.1)
HB ELECTROPHORESIS/ HPLC, SERUM FERRITIN(6
monthly)reqCase Sheet With Records Of Chelation Therapy
655Pediatrics Medical
Management
Haemophilia Including - 7 Days
Stay (M6S13.2)
VON WILL BRANDS / FACTOR VIII/ IX ASSAY
Coagulation Parameters
Post procedure Evidence of
clinical imrovement , case sheet with records of
factor given
656Pediatrics Medical
Management
Anaemia Of Unknown Cause 5
Days Stay (M6S13.3)
BONE MARROW EAMINATION SOS, HAEMOGRAM
/ HB ELECTROPHORESIS
Post procedure Evidence of clinical imrovement
AND LAB INVESTIGATIONS ( CBC)
657Pediatrics Medical
ManagementPyogenic Meningitis with 10 days stay (M6S14.1) X- RAY CHEST, CSF ANALYSIS
Post Procedure Evidence Of Clinical Imrovement
And Csf Analysis
658
Pediatrics
Medical
Management
Neuro Tuberculosis- 12 Days
Stay (M6S14.2)CT- SCAN BRAIN, CSF ANALYSIS, X- RAY CHEST
Post procedure Evidence of
clinical imrovement AND LAB INVESTIGATIONS
659
Pediatrics
Medical
Management
Neuro Tuberculosis With
Ventilation- 12 Days Stay
(M6S14.3)
CT- SCAN BRAIN, CSF ANALYSIS, X- RAY CHEST,
ABG
Post procedure Evidence of
clinical imrovement ,LAB
INVESTIGATIONS
660Pediatrics Medical
ManagementSuspected Dengue Shock Syndrome With Thrombocytopenia (M6S14.4)
CBC (PLATELET COUNT) / Dengue
SEROLOGY
EVIDENCE OF PLATELET TRANSFUSION If given,
CBC
661
Pediatrics
Medical
Management
Cerebral Malaria (Falciparum)
7 Days Stay (M6S14.5)
Test for P. Falciparum PARASITE , CSF ANALYSIS,
Blood sugar
Post procedure Evidence of
clinical imrovement ,LAB
INVESTIGATIONS
662Pediatrics Medical
ManagementConvulsive Disorders/Status Epilepticus (Fits) - 7 Days Stay (M6S15.1) BLOOD SUGAR, ELECTROLYTES
Post procedure Evidence of
clinical imrovement ,LAB INVESTIGATIONS EEG /
CT- brain,
663
Pediatrics
Medical
Management
Stroke Syndrome 14 days stay
(M6S15.2)CT
post treatment evidence of clinical and lab
investigation
664
Pediatrics
Medical
Management
Encephalitis / Encephalopathy
- 10 Days Stay (M6S15. 3)CSF Analysis, CT-brain/ MRI
Post procedure Evidence of
clinical imrovement ,LAB INVESTIGATIONS
665Pediatrics Medical
Management
Guillian-Barre Syndrome- 15
Days Stay (M6S15.4)
ENMG NERVE CONDUCTION STUDIES, CSF
ANALYSIS optional, S. electrolytes mandatory
during preauth.If NCS report is not positive then
in that case CSF analysis should show increase in
protein to confirm dignosis
Post procedure Evidence of clinical imrovemen,
LAB INVESTIGATIONS
666
Pediatrics
Medical
Management
Severe Bronchiolitis (Non
Ventilated) (M6S2.1)X- RAY CHEST, CLINICAL PHOTOGRAPH X-ray
667
Pediatrics
Medical
Management
Severe Bronchiolitis
(Ventilated) (M6S2.2)X- RAY CHES, ABG, CLINICAL PHOTOGRAPH X-ray, ABG
668Pediatrics Medical
Management
Severe Bronchopneumonia
(Non Ventilated) (M6S2.3)
X-Ray Chest ABG MANDATORY
AT TIME OF PREAUTHX-ray
669Pediatrics Medical
Management
Severe Bronchopneumonia
(Ventilated) (M6S2.4)
Clinical photo with ventilatory support SERIAL
ABG, X-RAY CHESTX-ray, ABG
670
Pediatrics
Medical
Management
Acute Severe Asthma
(Ventilated) (M6S2.5)
Clinical photo with ventilatory support SERIAL
ABG, X-RAY CHESTX-ray, ABG
671
Pediatrics
Medical
Management
Severe Aspiration Pneumonia
(Non Ventilated) (M6S2.6)X-RAY CHEST
Post procedure Evidence of
clinical imrovement AND
Xray, LAB INVESTIGATIONS
672Pediatrics Medical
Management
Severe Aspiration Pneumonia
(Ventilated) (M6S2.7)
Clinical photo with ventilatory support SERIAL
ABG, X-RAY CHEST
Post procedure Evidence of clinical imrovement
AND Xray chest, ABG
673
Pediatrics
Medical
Management
ARDS With Multi- Organ
Failure (M6S2.8)
ABG, X- RAY CHEST, RFT ,LFT, CLINICAL
PHOTOGRAPH
ABG, LAB INVESTIGATIONS
(LFT, RFT), Xray chest
BLOOD CULTURE AT CLAIM
674Pediatrics Medical
Management
ARDS Plus Dic (Blood & Blood
Products) (M6S2.9)
ABG optional, X- RAY CHEST, COAGULATION
PROFILE
Xray chest, LAB
INVESTIGATIONS( Coagulation profile optional)
BLOOD CULTURE AT CLAIM
675Pediatrics Medical
ManagementSevere Myocarditis (M6S3.1) ECG, 2 D Echo, Xray chest
Post Procedure Evidence Of Clinical
Imrovement And X-Ray
676Pediatrics Medical
ManagementCongenital Heart Disease With Infection (Non Ventilated) (M6S3.2) CBC / CRP , 2 D ECHO, X-RAY CHEST
Post procedure Evidence of clinical imrovement
AND X- ray
677Pediatrics Medical
Management
Congenital Heart Disease With Infection And Cardiogenic Shock
(Ventilated) (M6S3.3)
X- RAY CHEST, SERIAL ABG,
2DECHO, clinical photo with ventilatory support
Post procedure Evidence of clinical imrovement
Photo AND ABG, X-ray
678Pediatrics Medical
ManagementAcquired heart disease with congestive cardiac failure (M6S11.3) X-Ray, 2D Echo, ECG
post treatment evidence of
X-Ray Chest, 2D Echo, ECG
679
Pediatrics
Medical
Management
Cardiogenic Shock (M6S3.4) X-RAY CHEST, ECHO /CVP Monitoring
Post procedure Evidence of
clinical imrovement Photo
AND X-ray
680
Pediatrics
Medical
Management
Infective Endocarditis (M6S3.5) CBC, CRP/ BLOOD CULTURES X- RAY CHEST, ECHO
Post procedure Evidence of
clinical imrovement Photo
AND Blood culture
681Pediatrics Medical
Management
Meningo-Encephalitis (Non
Ventilated) (M6S4.1)CSF ANALYSIS, CT- SCAN
Post procedure Evidence of
clinical imrovement AND LAB INVESTIGATIONS (
CSF analysis)
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
682Pediatrics Medical
Management
Meningo- Encephalitis
(Ventilated) (M6S4.2)
SERIAL ABG, CT- SCAN, CSF ANALYSIS, Clinical
photo with ventilatory support
Post procedure Evidence of
clinical imrovement AND
LAB INVESTIGATIONS ( CSF
analysis)
683Pediatrics Medical
ManagementStatus Epilepticus (M6S4.3) Clinical Notes, EEG optional
Post procedure Evidence of
clinical imrovement WITH LAB
INVESTIGATIONS, EEG/ CT scan
684Pediatrics Medical
ManagementFebrile Seizures (Atypical- Mechanical Ventilated) (M6S4.4) CSF ANALYSIS, SERIAL ABG,
Post procedure Evidence of clinical imrovement
WITH LAB INVESTIGATIONS, EEG/ CT scan
685
Pediatrics
Medical
Management
Intra Cranial Bleed (M6S4.5) CT- SCAN/ MRIPost procedure Evidence of
clinical imrovement WITH LAB INVESTIGATIONS
686Pediatrics Medical
Management
Acute Pancreatitis - 10 Days
Picu Stay (M6S5.2)
SERUM AMYLASE, LIPASE, USG/CT SCAN
ABDOMEN
Post procedure Evidence of
clinical imrovement WITH LAB
INVESTIGATIONS( Sr. Amylase, Sr lipase)
687Pediatrics Medical
Management
Acute Hepatitis With Hepatic Encephalopathy – 10 Days Picu Stay
(M6S5.3)
LFT, / S. AMMONIA, HEPATIC VIRAL STUDIES
(HEPATITIS B, HEPATITIS
C), (HEPATITIS A optional) SERIAL ABG, BLOOD
SUGAR LEVELS, USG MANDATORY AT PREAUTH
Post procedure Evidence of clinical imrovement
WITH LAB INVESTIGATIONS ( LFT, Sr. Ammonia)
688Pediatrics Medical
ManagementAcute Renal Failure With Dialysis - 10 Days Picu Stay (M6S6.1)
RFT, SERUM ELECTROLYTES, XRAY
CHEST, USG MANDATORY
Post Procedure Evidence Of Clinical Imrovement
And Lab Investigations (Rft)
689Pediatrics Medical
Management
Septic Shock- 10 Days Picu Stay
(M6S8.1)
CBC/CRP / BLOOD CULTURE, X- RAY CHEST
SERIAL ABG, BLOOD SUGAR LEVELS MANDATORY
AT PREAUTH
Post procedure Evidence of clinical imrovement
WITH LAB INVESTIGATIONS(CBC, CRP)
690
Pediatrics
Medical
Management
Acute Gastro intestinal bleed
(M6S5.1)Upper GI Endoscopy
post treatment evidence for
Clinical Improvement with lab investigations,
691Pediatrics Medical
Management
Diabetic Ketoacidosis
(M6S7.1)
ABG optional, Blood sugar, Urine
Ketone
post treatment evidence for
Clinical Improvement with biochemical
parameters, Blood Sugar,
692Pediatrics Medical
ManagementSnake bite requiring ventilatory assistance (M6S9.1) Serial ABG, coagulation profile(optional)
PICU stay with post
treatment evidence for
Clinical Improvement with biochemical
parameters, ABG
693Pediatrics Medical
Management
Scorpion sting with myocarditis and cardiogenic shock requiring
ventilatory Assistance (M6S9.2)
Serial ABG, Echo, ECG, CVP
monitoring
post treatment evidence for Clinical
Improvement with lab investigations
694Pediatrics Medical
ManagementPoison ingestion/ aspiration requiring ventilatory assistance (M6S9.3)
Serial ABG, CVP
monitoring(optional)
post treatment evidence for Clinical
Improvement with biochemical parameters,
MLC
695 Plastic Surgery Cleft lip (S12M1.1) Clinical photo of affected partClinical photo of affected
part
696 Plastic Surgery Cleft Palate (S12M1.2) Clinical photo of affected partClinical photo of affected
part
697 Plastic SurgeryVelo-Pharyngial Incompetence
(S12M1.3)Naso Endoscopy / Fluroscopy Clinical photo of affected part
698 Plastic Surgery Syndactyly of Hand for each hand (S12M1.4) Clinical photo of affected part Clinical photo of affected part
699 Plastic Surgery Microtia/Anotia (S12M1.5) Clinical photo of affected partClinical photo of affected
part
700 Plastic Surgery TM joint ankylosis (S12M1.6) Clinical Phoptograph, X-Ray / OPGClinical Phoptograph / OPG/
Xray
701 Plastic SurgeryHemifacial Microsomia
(S12M1.7)CT/ Xray / OPG Clinical photo of affected part
702 Plastic SurgeryLeprosy reconstructive surgery
(S12M1.8)Clinical photograph Clinical photo of affected part
703 Plastic Surgery Nerve and tendon repair + Vascular repair (S12M1.9) Clinical photograph Clinical photo of affected part
704 Plastic Surgery Ptosis (S12M1.10) Clinical photo of affected partClinical photo of affected
part
705 Plastic Surgery Tumour of mandible and maxilla (S12M1.11) CT/MRI/Xray/HPE clinical photograph Clinical Phoptograph/ Xray, Biopsy report
706 Plastic Surgery Vaginal atresia (S12M1.12) Clinical notes with sketch Sketch/ Clinical photograph
707 Plastic SurgeryVascular malformations
(S12M1.13)Angiogram / MR angio/ CT angio Clinical photo of affected part
708 Plastic SurgeryCorrective Surgery for Congenital deformity of hand (per hand)
(S12M1.14)X-Ray, clinical photograph Clinical Phoptograph/ Xray
709 Plastic SurgeryCorrective Surgery for
Craniosynostosis (S12M1.15)CT, Clinical photograph Clinical photo of affected part
710 Plastic Surgery Cup and Bat ears (S12M1.16) Clinical photo of affected partClinical photo of affected
part
711 Plastic Surgery Flap cover for Electrical burns with vitals exposed (S12M1.17) Clinical photo of affected part Clinical photo of affected part
712 Plastic Surgery Reduction surgery for Filarial lymphedema (S12M1.18) Clinical photo of affected part Clinical photo of affected part
713 Plastic Surgery Hemifacial atrophy (S12M1.19) Clinical photographClinical photo of affected
part
714 Poly Trauma Soft Tissue Injury(S14O1.3) clinical photo clinical photo
715 Poly Trauma Amputation Surgery (S14O1.2) X- RAYPost procedure clinical
photograph
716 Poly Trauma Open Reduction And Internal Fixation Of Long Bone Fractures (S14O1.1) X rayX ray,
OT Notes
717 Poly Trauma Grade I& II (S14O10.1) CLINICAL PHOTOGRAPH, X- RAYPost procedure clinical
photograph OT Notes
718 Poly Trauma Surgical Correction Of Pelvic Bone Fractures. (S14O11.6) X- RAY X- RAY OT Notes
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
719 Poly Trauma Facial Bone Fractures (Faciomaxillary Injuries) (S14O11.5) CLINICAL PHOTOGRAPH, X- RAYPost procedure clinical photograph, X- RAY
OT Notes
720 Poly TraumaSmall Bone Fractures K-Wiring (To Be Covered With Other Injuries Only
And Not As Exclusive Procedure) (S14O11.4)X- RAY
X- RAY
OT Notes
721 Poly TraumaSurgery For Patella Fracture (To Be Covered With Other Injuries Only
And Not As Exclusive Procedure)(S14O11.3)X- RAY
X ray
OT Notes
722 Poly Trauma Flap Cover Surgery For Wound In Compound Fracture (S14O11.2) CLINICAL PHOTOGRAPH, X- RAYPost procedure clinical photograph, Xray
OT Notes
723 Poly Trauma Grade -III (S14O11.1) CLINICAL PHOTOGRAPHPost procedure clinical
photograph
724 Poly TraumaStay In Neuro
[email protected]/Day (S14O2.2)X- RAY/ CT/ MRI Post procedure clinical photograph
725 Poly TraumaStay In General Ward
@Rs.500/ Day (S14O2.1)X- RAY/ CT Post procedure clinical photograph
726 Poly Trauma Surgical Treatment (Up To) (S14O3.1)
X- RAY/CT/MRI, It includes following
neurosurgical procedures carried out on
polytrauma patient For example -Craniotomy for
extradural and subdural hematoma,
decompressiion craniotomy, elevation of all
depressed fractures and surgeries for CSF leak,
emergency surgery for high ICP and cranioplasty.
Post procedure clinical photograph, Lab
Investigation
727 Poly TraumaStay In Respiratory Icu
[email protected]/Day (S14O4.2)X- RAY/CT, Clinical photograph Post procedure clinical photograph
728 Poly Trauma
Chest Injuries Conservative
Stay In General Ward
@Rs.500/Day (S14O4.1)
X- RAY/CT Post procedure clinical photograph
729 Poly Trauma Polytrauma Chest Surgical Treatment (S14O5.1) X-RAY/USG/CT X-Ray/Usg/Ct
730 Poly TraumaStay In Surgical
[email protected]/Day (S14O6.2)X-RAY/USG/CT USG
731 Poly TraumaAbdominal Injuries Conservative Stay In General Ward @Rs.500/Day
(S14O6.1)X-RAY/USG/CT USG
732 Poly TraumaAbdominal Injuries Surgical
Treatment(S14O7.1)
X-RAY/USG/CT .It includes abdominal trauma
management of polytrauma patient which include
Spleenectomy, Mesentric artery tears, Bowel
tears, Liver injuries, Intraabdominal hemorrhage
USG, Post procedure clinical photograph
733 Poly Trauma Thoracostomy(S14O8.2) CLINICAL PHOTOGRAPHPost procedure clinical
photograph
734 Poly Trauma Tracheostomy(S14O8.1) CLINICAL PHOTOGRAPHPost procedure clinical
photograph
735 ProsthesesLower Limb Symes Prostheses
HDP/PP (S15P2.1)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
736 ProsthesesLower Limb Symes Prostheses
Fibre (S15P2.2)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH
clinical photograph with prosthesis mandatory
for claim
737 ProsthesesLower Limb Symes Prostheses
Modular (S15P2.3)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH
clinical photograph with
prosthesis mandatory for claim
738 Prostheses Below Knee(BK/PTB) Prostheses HDP/PP (S15P3.1) CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH
clinical photograph with prosthesis mandatory
for claim
739 Prostheses Below Knee(BK/PTB) Prostheses Fibre (S15P3.2) CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH
clinical photograph with prosthesis mandatory
for claim
740 Prostheses Below Knee(BK/PTB) Prostheses Modular (S15P3.3) CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH
clinical photograph with prosthesis mandatory
for claim
741 ProsthesesThrough Knee Prostheses
HDP/PP (S15P4.1)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH
clinical photograph with prosthesis mandatory
for claim
742 ProsthesesThrough Knee Prostheses Fibre
(S15P4.2)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
743 ProsthesesThrough Knee Prostheses
Modular (S15P4.3)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH
clinical photograph with prosthesis mandatory
for claim
744 ProsthesesAbove Knee(AK) Prostheses
HDP/PP (S15P5.1)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH
clinical photograph with prosthesis mandatory
for claim
745 ProsthesesAbove Knee(AK) Prostheses
Fibre (S15P5.2)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
746 ProsthesesAbove Knee(AK) Prostheses
Modular (S15P5.3)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
747 ProsthesesHip Disarticulation Prosthesis
HDP/PP (S15P6.1)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
748 ProsthesesHip Disarticulation Prosthesis
Fibre (S15P6.2)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
749 ProsthesesHip Disarticulation Prosthesis
Modular (S15P6.3)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
750 ProsthesesHip Disarticulation Partial Foot
Prosthesis (S15P6.4)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
751 ProsthesesBelow Elbow Prosthesis
HDP/PP (S15P7.1)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
752 ProsthesesBelow Elbow Prosthesis Fibre
(S15P7.2)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
753 ProsthesesBelow Elbow Prosthesis
Modular (S15P7.3)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
754 ProsthesesAbove Elbow Prosthesis
HDP/PP (S15P7.4)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
755 ProsthesesAbove Elbow Prosthesis Fibre
(S15P7.5)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
756 ProsthesesAbove Elbow Prosthesis
Modular (S15P7.6)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
757 ProsthesesWhole Upper Limb Prosthesis
HDP/PP (S15P8.1)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
758 ProsthesesWhole Upper Limb Prosthesis
Fibre (S15P8.2)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
759 ProsthesesWhole Upper Limb Modular
HDP/PP (S15P8.3)CLINICAL PHOTOGRAPH
CLINICAL PHOTOGRAPH clinical photograph
with prosthesis mandatory for claim
760 Pulmonology Bronchiectasis requiring hospitalisation (M10T4.8) HR CT - Chest , sputum gram stain
post treatment evidence of Clinical and Lab
Investigations, Sputum culture /drug
susceptibility
761 PulmonologyLung Abscess, non resolving
(M10T4. 1)CT Scan Chest,
post treatment evidence of Clinical and Lab
Investigations, Pus C/S
762 PulmonologyPneumothorax
(Large/Recurrent) (M10T4.2)Chest HRCT
post treatment evidence of Clinical and Lab
Investigations Xray
763 PulmonologyInterstitial Lung diseases
(M10T4. 3)HRCT Chest
post treatment evidence of Clinical and Lab
Investigations, Spirometry
764 Pulmonology Pneumoconiosis (M10T4. 4) HRCT Chestpost treatment evidence of Clinical and Lab
Investigations
765 PulmonologyAcute Respiratory Failure
(without ventilator) (M10T4.5)
Serum Electrolytes, ABG, ECG, Sputum / Bronchial
Washing / ET Suctions for Analysis x ray
mandatory for pre auth.
post treatment evidence of Clinical and Lab
Investigations
766 Pulmonology Acute Respiratory Failure (with ventilator) (M10T4.6)
Serum Electrolytes, ABG, ECG, Sputum / Bronchial
Washing / ET Suctions for Analysis x ray
mandatory for pre auth.
post treatment evidence of Clinical and Lab
Investigations
767 Radiation Oncology Cobalt 60 External Beam Radiotherapy (M2L1.1) Radical TreatmentBiopsy/Histopathology report, USG/CT/X-RAY/or
any other relevent Imaging
RT Treatment Charts, For planning phase-
marker cell or simulation cell report
768 Radiation Oncology Cobalt 60 External Beam Radiotherapy (M2L1.2) Palliative TreatmentBiopsy/Histopathology report, USG/CT/X-RAY/or
any other relevent Imaging
RT Treatment Charts, For planning phase-
marker cell or simulation cell report
769 Radiation Oncology Cobalt 60 External Beam Radiotherapy (M2L1.3) Adjuvant TreatmentBiopsy/Histopathology report,USG/CT/X-RAY/or
any other relevent Imaging
RT Treatment Charts, For planning phase-
marker cell or simulation cell report
770 Radiation OncologyExternal Beam Radiotherapy (On Linear Acclerator) (M2L2.1) Radical
Conventional Treatment with Photons
Biopsy/Histopathology report, USG/CT/X-RAY/or
any other relevent Imaging
RT Treatment Charts, For planning phase-
marker cell or simulation cell report
771 Radiation OncologyExternal Beam Radiotherapy (On Linear Acclerator) (M2L2.2) Palliative
Treatment With Photons
Histopathology report, USG/CT/X-RAY/or any
other relevent Imaging
RT Treatment Charts, For planning phase-
marker cell or simulation cell report
772 Radiation OncologyExternal Beam Radiotherapy (On Linear Acclerator) (M2L2.3) Adjuvant
Treatment With Photons/Electrons
Histopathology report, USG/CT/X-RAY/or any
other relevent Imaging
RT Treatment Charts, For planning phase-
marker cell or simulation cell report
773 Radiation OncologyBrachytherapy Intracavity (M2L3.1) A) Intracavitary I. LDR Per
Application
Histopathology report, USG/CT/X-RAY/or any
other relevent Imaging
Brachytherapy Details, For planning phase-
marker cell or simulation cell report
774 Radiation OncologyBrachytherapy Intracavity (M2L3.2) A) Intracavitary II. HDR Per
Application
Histopathology report, USG/CT/X-RAY/or any
other relevent Imaging
Brachytherapy Details, For planning phase-
marker cell or simulation cell report
775 Radiation OncologyBrachytherapy Interstitial (M2L4.1) B) Interstitial I. LDR Per Application/
Surface mould (LDR/HDR)
Histopathology report, USG/CT/X-RAY/or any
other relevent Imaging
Brachytherapy Details with Simulation X-ray or
CT Scan or MRI or USG, For planning phase-
marker cell or simulation cell report
776 Radiation Oncology
Brachytherapy Interstitial (M2L4.2) B) Interstitial II. HDR One
Application and Single/Multiple Dose Fractions (For Current Rate) &
Interstitial Implant with Complete Treatment
Histopathology report, USG/CT/X-RAY/or any
other relevent Imaging
Brachytherapy Details and Implant simulation X-
ray or CT scan or MRI or USG, For planning
phase- marker cell or simulation cell report
777 Radiation OncologySpecialized Radiation Therapy - Imrt (Intensity Modulated
Radiotherapy)
Biopsy/Histopathology report,USG/CT/X-RAY/or
any other relevent Imaging
RT TREATMENT CHARTS, For planning phase- CT
planning image, Claim will be paid as per
adjudication guidelines
778 Radiation OncologySpecialized Radiation Therapy - 3dcrt(3-D Conformational
Radiotherapy) (M2L6.1) 3DCRT-Up To 30 Fractions In 6 Weeks
Biopsy/Histopathology report, USG/CT/X-Ray/or
any other relevent Imaging
RT TREATMENT CHARTS, For planning phase- CT
planning image, Claim will be paid as per
adjudication guidelines
779 Radiation OncologySpecialized Radiation Therapy - SRS/SRT (M2L7.1) SRS (1 or 2
fractions)/SRT- more than 25 fractions
Biopsy/Histopathology report,USG/CT/X-RAY/or
any other relevent Imaging
RT TREATMENT CHARTS, For planning phase- CT
planning image, Claim will be paid as per
adjudication guidelines
780 Radiation OncologySpecialized Radiation Therapy Volumetric IMRT (Rapid Arc/VMAT/or
Any other commercial Volumetric IMRT) Therapy (M2L8.1)
Biopsy/Histopathology report,USG/CT/X-RAY/or
any other relevent Imaging
RT TREATMENT CHARTS, For planning phase- CT
planning image, Claim will be paid as per
adjudication guidelines
781 Radiation OncologySpecialized Radiation Therapy - IMRT with IGRT (M2L9.1) IMRT+IGRT-
Up To 40 Fractions In 8 Weeks
Biopsy/Histopathology report,USG/CT/X-RAY/or
any other relevent Imaging
RT TREATMENT CHARTS, For planning phase- CT
planning image, Claim will be paid as per
adjudication guidelines
782 RheumatologySLE (Systemic Lupus Erythematosis) 10 Days
Stay(M12T6.6)
24 Hour urine protein, ACL Antibodies / ANA/ Anti
DSDNA/ C3 C4
Post treatment evidence of clinical
improvement, Lab Investigation
783 Rheumatology SLE with Sepsis 4 weeks stay (M12T6. 1)ANA/Anti DSDNA (new or old
report), Blood Culture or source of infection
Post treatment evidence of clinical
improvement, Lab Investigation
784 Rheumatology Scleroderma 7 Days stay (M12T6. 2) Anti SCL 70, ANA (old or new) / skin biopsy/ PFTPost treatment evidence of Clinical
improvement, Lab Investigation
785 Rheumatology MCTD Mixed connective tissue disorder 7 days stay (M12T6. 3)ANA, Anti U1 RNP ab, (old or new)
/Renal biopsy/ CPK
Post treatment evidence of clinical
improvement, Lab Investigation
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
786 Rheumatology Primary Sjogren's Syndrome 7 days stay (M12T6.4)ANA, Anti-Ro & Anti- La antibody
(old or new)
Post treatment evidence of
clinical improvement, Lab Investigation
787 RheumatologyVasculitis 10 days stay
(M12T6. 5)ANCA<PC, ANA / Renal biopsy/ Skin biopsy/ NCS
Post treatment evidence of clinical
improvement, Lab Investigation
788Surgical
Gastroenterology
Diaphragmatic Hernia (Gortex
Mesh Repair) (S6E1.3)
X- ray,
USG and Barium study mandatory during preauthpostop plain x ray & intaoperative photo
789Surgical
Gastroenterology
Surgery For Obscure GI Bleed
(S6E1.2)ENDOSCOPY ENDOSCOPIC PHOTOGRAPH/ Sketch
790Surgical
Gastroenterology
Surgery For Bleeding Ulcers
(S6E1.1)ENDOSCOPY
ENDOSCOPIC PHOTOGRAPH/ Sketch Endoscopic
photograph mandatory at time of claims.
Sketch cannot be accepted
791Surgical
Gastroenterology
Hepatico Jejunostomy
(S6E11.2)USG, MRCP Post procedure clinical photograph
792Surgical
Gastroenterology
Gb+ Calculi Cbd Stones Or
Dilated Cbd (S6E11.1)USG
Post treatment evidence of clinical
improvement and USG
793Surgical
GastroenterologyCholedo choduodenostomy Or Choledocho Jejunostomy (S6E11.3)
USG, MRCP LFT
required for pre authhistopath,CLINICAL PHOTOGRAPH
794Surgical
GastroenterologySplenectomy(S6E12.1)
CT/USG abdomen, lab
investigations
Post procedure clinical photograph,
USG,histopath
795Surgical
GastroenterologySplenectomy + Devascularisation + Spleno Renal Shunt(S6E12.2) USG, UGI Scopy BIOPSY,CLINICAL PHOTOGRAPH
796Surgical
Gastroenterology
Spleenectomy For Space
Occupying Lesion(S6E12.3)
CT / USG
BIOPSY MANDATORY AT TIME OF PREAUTHCLINICAL PHOTOGRAPH, USG
797Surgical
GastroenterologyCysto Gastrostomy (S6E14.2) CT/USG abdomen Post procedure clinical photograph, USG
798Surgical
GastroenterologyCysto Jejunostomy (S6E14.1) CT/USG abdomen Post procedure clinical photograph, USG
799Surgical
GastroenterologyRt Hepatectomy(.S6E21) CT, USG CLINICAL PHOTOGRAPH, USG, Biopsy
800Surgical
GastroenterologyLt Hepatectomy(S6E2.2) CT, USG CLINICAL PHOTOGRAPH, USG, Biopsy
801Surgical
GastroenterologySegmentectomy(S6E2.3) CT, USG
CLINICAL PHOTOGRAPH,
USG, Biopsy
802Surgical
GastroenterologyHepato Cellular Carcinoma(Advanced) Radio Frequency Ablation (S6E2.4)BIOPSY, USG/ CT- SCAN, Tumor marker (AFP)
Post procedure clinical photograph, USG, Intra
Op Photo
803Surgical
GastroenterologyHaemangioma Sol Liver Hepatectomy + Wedge Resection(S6E2.5) CT- SCAN, USG BIOPSY, CLINICAL PHOTOGRAPH
804Surgical
Gastroenterology
Hydatid Cyst-Marsupilisation
(S6E2.6)USG / CT- SCAN BIOPSY, CLINICAL PHOTOGRAPH
805Surgical
Gastroenterology
Cyst Excision + Hepatic
Jejunostomy (S6E2.7)CT, USG histopath,CLINICAL PHOTOGRAPH
806Surgical
Gastroenterology
Pancreatic Necrosectomy
(Open) (S6E3.8)
CT- SCAN
serum amylase required for pre authBIOPSY, Post procedure clinical photograph
807Surgical
GastroenterologyWhipples Any Type (S6E3.3) CT/ USG, ERCP, Clinical Photograph BIOPSY,Post procedure clinical photograph, USG
808Surgical
GastroenterologyEnucleation Of Cyst (S6E3.2) CT/USG histopath,CLINICAL PHOTOGRAPH
809Surgical
Gastroenterology
Distal Pancreatectomy
(S6E3.1)
CT serum amylase
required for pre authBIOPSY,Post procedure clinical photograph, USG
810Surgical
Gastroenterology
Central
Pancreatectomy(S6E3.10)CT- SCAN BIOPSY, CLINICAL PHOTOGRAPH
811Surgical
GastroenterologyTriple Bypass(S6E3.4) CT CLINICAL PHOTOGRAPH,USG
812Surgical
GastroenterologyOther Bypasses(S6E3.5) CT CLINICAL PHOTOGRAPH,USG
813Surgical
Gastroenterology
Lap- Pancreatic Necrosectomy
(S6E3.6)CT- SCAN BIOPSY,CLINICAL PHOTOGRAPH
814Surgical
GastroenterologyLateral Pancreaticojejunostomy(Non- Malignant) (S6E3.7) CT- SCAN BIOPSY,CLINICAL PHOTOGRAPH
815Surgical
GastroenterologyDistal Pancreatectomy + Splenectomy (S6E3.9) CT- SCAN BIOPSY,CLINICAL PHOTOGRAPH
816Surgical
GastroenterologyColonic Pull Up (S6E4.1) BIOPSY, ENDOSCOPY, CT- SCAN CLINICAL PHOTOGRAPH,USG
817Surgical
GastroenterologyOesophagectomy (S6E4.2) BIOPSY, ENDOSCOPY, CT- SCAN CLINICAL PHOTOGRAPH,USG
818Surgical
Gastroenterology
Oesophago-Gastrectomy
(S6E4.3)BIOPSY, ENDOSCOPY, CT- SCAN
BIOPSY, ENDOSCOPIC PHOTOGRAPH/ Sketch
Endoscopic photograph mandatory at time of
claims. Sketch cannot be accepted
819Surgical
GastroenterologyLap Heller’S Myotomy (S6E4.4) ENDOSCOPY
BIOPSY, ENDOSCOPIC PHOTOGRAPH/ Sketch
Endoscopic photograph mandatory at time of
claims. Sketch cannot be accepted
820Surgical
GastroenterologyLap Fundoplications (S6E4.5) ENDOSCOPY
BIOPSY, ENDOSCOPIC PHOTOGRAPH/ Sketch
Endoscopic photograph mandatory at time of
claims. Sketch cannot be accepted
821Surgical
GastroenterologyPartial Gastrectomy (S6E5.1) BIOPSY, USG, Endoscopic photograph mandatory histopath,CLINICAL PHOTOGRAPH
822Surgical
GastroenterologyTotal Gastrectomy (S6E5.2) BIOPSY,USG,ENDOSCOPY,CT- SCAN Histopath,Post procedure clinical photograph
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
823Surgical
Gastroenterology
Truncal Vagotomy + Gastro
Jejunostomy (S6E5.3)USG / CT- SCAN
CLINICAL PHOTOGRAPH Biopsy mandatory at
time of claims
824Surgical
Gastroenterology
Distal Gastrectomy For Gastric
Outlet Obstruction (S6E5.4)BIOPSY,USG,ENDOSCOPY,CT- SCAN BIOPSY,CLINICAL PHOTOGRAPH
825Surgical
Gastroenterology
Surgery For Corrosive Injury
Stomach (S6E5.5)ENDOSCOPY /Sketch BIOPSY, CLINICAL PHOTOGRAPH
826Surgical
GastroenterologyLap Adhesiolysis (S6E6.3) CT- SCAN/X-RAY ABD
Post procedure clinical photograph, USG
Biopsy required at time of claims
827Surgical
GastroenterologyMalrotation (S6E6.2) CT- SCAN/X-RAY ABD
Post procedure clinical photograph Biopsy
required at time of claims
828Surgical
GastroenterologyVolvulus (S6E6.1) CT- SCAN/X-RAY ABD
Post procedure clinical photograph Biopsy
required at time of claims
829Surgical
GastroenterologyRight Hemicolectomy (S6E7.1) BIOPSY, ENDOSCOPY, CT- SCAN, COLONOSCOPY BIOPSY,CLINICAL PHOTOGRAPH
830Surgical
GastroenterologyLeft Hemicolectomy (S6E7.2)
BIOPSY, ENDOSCOPY, CT- SCAN,
COLONOSCOPYBIOPSY,CLINICAL PHOTOGRAPH
831Surgical
Gastroenterology
Extended Right
Hemicolectomy (S6E7.3)CT- SCAN/USG COLONOSCOPY BIOPSY,Post procedure clinical photograph, USG
832Surgical
GastroenterologyAnterior Resection (S6E7.4)
BIOPSY, ENDOSCOPY, CT- SCAN,
COLONOSCOPYBIOPSY,CLINICAL PHOTOGRAPH
833Surgical
Gastroenterology
Anterior Resection With
Ileostomy (S6E7.5)CT- SCAN/ USG, COLONOSCOPY BIOPSY,Post procedure clinical photograph, USG
834Surgical
Gastroenterology
Abdomino Perineal
Resection(Non- Malignant) (S6E7.6)BIOPSY, ENDOSCOPY, CT- SCAN, COLONOSCOPY BIOPSY,CLINICAL PHOTOGRAPH
835Surgical
Gastroenterology
Hartman.S Procedure With
Colostomy (S6E7.7)BIOPSY, ENDOSCOPY, CT- SCAN, COLONOSCOPY BIOPSY,CLINICAL PHOTOGRAPH
836Surgical
GastroenterologyI Stage-Sub Total Colectomy + Ileostomy (S6E8.1) COLONOSCOPY BIOPSY, CLINICAL PHOTOGRAPH
837Surgical
GastroenterologyIi Stage-J - Pouch (S6E8.2)
CLINICAL PHOTOGRAPH COLONOSCOPY
MANDATORY AT TIME OF PREAUTHCLINICAL PHOTOGRAPH
838Surgical
Gastroenterology
III Stage-Ileostomy Closure
(S6E8.3)CT Scan contrast/ USG
BIOPSY, Post procedure
clinical photograph, USG
839Surgical
GastroenterologyI Stage- Sub Total Colectomy + Ileostomy + J - Pouch (S6E9.1) COLONOSCOPY BIOPSY, CLINICAL PHOTOGRAPH
840Surgical
GastroenterologyIi Stage- Ileostomy (S6E9.2) COLONOSCOPY CLINICAL PHOTOGRAPH
841Surgical
Oncology
Hemimandibulectomy
(S11J1.10)
BIOPSY, X-RAY AT TIME OF
PREAUTH
HPE, Operative notes, Post procedure clinical
photograph
842Surgical
Oncology
Laryngo Pharyngo
Oesophagectomy (S11J1.9)
BIOPSY, X-RAY AT TIME OF
PREAUTH
HPE, Operative notes, Post procedure clinical
photograph
843Surgical
Oncology
Laryngectomy Any Type
(S11J1.8)BIOPSY, clinical & radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
844Surgical
Oncology
Parotidectomy Any Type
(S11J1.7)BIOPSY, X- RAY, USG, CLINICAL PHOTOGRAPH
HPE, Operative notes, Post
procedure clinical photograph
845Surgical
Oncology
Thyroidectomy Any Type
(S11J1.6)
BIOPSY/FNAC, clinical &
radiological evidence
HPE, Operative notes, Post
procedure clinical photograph
846Surgical
Oncology
Maxillectomy Any Type
(S11J1.5)BIOPSY, clinical & radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
847Surgical
OncologyHemiglossectomy (S11J1.4)
BIOPSY,
RADIOLOGICAL EVIDENCE MANDATORY AT TIME
OF PREAUTH
HPE, Operative notes, Post procedure clinical
photograph
848Surgical
Oncology
Neck Dissection Any Type
(S11J1.3)BIOPSY, clinical & radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
849Surgical
OncologyWide Excision (S11J1.2) BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
850Surgical
OncologyComposite Resection & Reconstruction(S11J1.1)
BIOPSY
RADIOLOGICAL EVIDENCE MANDATORY AT TIME
OF PREAUTH
HPE, Operative notes, Post procedure clinical
photograph
851Surgical
OncologyOrbital Exenteration (S11J2.1) BIOPSY/ CLINICAL AND RADIOLOGICAL EVIDENCE
HPE, Operative notes, Post procedure clinical
photograph
852Surgical
Oncology
Maxillectomy + Orbital
Exenteration (S11J2.2)BIOPSY/ CLINICAL AND RADIOLOGICAL EVIDENCE
HPE, Operative notes, Post procedure clinical
photograph
853Surgical
Oncology
Maxillectomy + Infratemporal
Fossa Clearance (S11J2.3)BIOPSY/ CLINICAL AND RADIOLOGICAL EVIDENCE
HPE, Operative notes, Post procedure clinical
photograph
854Surgical
Oncology
Cranio Facial Resection
(S11J2.4)
BIOPSY/ CLINICAL AND
RADIOLOGICAL EVIDENCE
HPE, Operative notes, Post procedure clinical
photograph
855Surgical
Oncology
Resection Of Nasopharyngeal
Tumour (S11J3.1)Biopsy/Clinical and radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
856Surgical
Oncology
Palatectomy Any Type
(S11J4.1)Biopsy
HPE, Operative notes, Post procedure clinical
photograph
857Surgical
OncologySleeve Resection (S11J5.1) Biopsy
HPE, Operative notes, Post procedure clinical
photograph
858Surgical
Oncology
Lateral Temporal Bone
Resection (S11J5.2)
Biopsy/FNAC/ Clinical and
Radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
859Surgical
Oncology
Subtotal Temporal Bone
Resection (S11J5.3)
Biopsy/FNAC/ Clinical and
Radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
860Surgical
Oncology
Total Temporal Bone Resection
(S11J5.4)
Biopsy/FNAC/ Clinical and
Radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
861Surgical
Oncology
Submandibular Gland Excision
(S11J6.1)
Biopsy/FNAC/ Clinical and
Radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
862Surgical
OncologyTracheal Resection (S11J7.1) Biopsy, CT
HPE, Operative notes, Post procedure clinical
photograph
863Surgical
OncologySternotomy + Superior Mediastinal Dissection (S11J8.1) Biopsy and Radiology (CT)
HPE, Operative notes, Post procedure clinical
photograph
864Surgical
OncologyTracheal Resection (S11J8.2) Biopsy, CT
HPE, Operative notes, Post procedure clinical
photograph
865Surgical
OncologyParathyroidectomy (S11J9.1) CT, S.PTH, NUCLEAR SCAN
HPE, Operative notes, Post procedure clinical
photograph
866Surgical
Oncology
Small Bowel Resection
(S11J10.1)clinical & radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
867Surgical
Oncology
Closure Of Ileostomy
(S11J10.2)COLONOSCOPY/Loopogram/Enema
HPE, Operative notes, Post procedure clinical
photograph
868Surgical
Oncology
Closure Of colostomy
(S11J10.3)COLONOSCOPY/Loopogram
HPE, Operative notes, Post procedure clinical
photograph
869Surgical
Oncology
Abdomino Perineal Resection
(Apr) + Sacrectomy (S11J10.4)BIOPSY, CT, COLONOSCOPY
HPE, Operative notes, Post procedure clinical
photograph
870Surgical
Oncology
Posterior Exenteration
(S11J11.1)BIOPSY, CT, COLONOSCOPY
HPE, Operative notes, Post procedure clinical
photograph
871Surgical
OncologyTotal Exenteration (S11J11.2) BIOPSY, CT, COLONOSCOPY
HPE, Operative notes, Post procedure clinical
photograph
872Surgical
OncologyWhipples Any Type (S11J12.6) BIOPSY, Clinical and radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
873Surgical
Oncology
Abdominoperineal Resection
(S11J12.5)CT, BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
874Surgical
OncologyAnterior Resection (S11J12.4) CT, BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
875Surgical
OncologyColectomy Any Type (S11J12.3) CT/ USG, ENDOSCOPY, BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
876Surgical
Oncology
Gastrectomy Any Type
(S11J12.2)CT/ USG, ENDOSCOPY, BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
877Surgical
Oncology
Oesophagectomy Any Type
(S11J12.1)CT, ENDOSCOPY, BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
878Surgical
OncologyTripple Bypass (S11J12.7) BIOPSY, Clinical and radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
879Surgical
Oncology
Other Bypasses- Pancreas
(S11J12.8)BIOPSY, Clinical and radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
880Surgical
Oncology
Radical Cholecystectomy
(S11J13.1)BIOPSY, Clinical and radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
881Surgical
OncologySplenectomy (S11J14.1) BIOPSY, Clinical and radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
882Surgical
Oncology
Resection Of Retroperitoneal
Tumours (S11J15.1)Biopsy, Clinical and radiological evidence
HPE, Operative notes, Post procedure clinical
photograph
883Surgical
Oncology
Resection With Reconstruction
(S11J16.2)
Biopsy
RADIOLOGICAL EVIDENCE MANDATORY AT TIME
OF PREAUTH
HPE, Operative notes, Post procedure clinical
photograph
884Surgical
Oncology
Abdominal Wall Tumour
Resection (S11J16.1)
Biopsy
RADIOLOGICAL EVIDENCE MANDATORY AT TIME
OF PREAUTH
HPE, Operative notes, Post procedure clinical
photograph
885Surgical
OncologyBilateral Pelvic Lymph node dissection (S11J17.1) CT, FNAC, BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
886Surgical
Oncology
Radical Trachelectomy
(S11J17.2)BIOPSY/ MRI
HPE, Operative notes, Post procedure clinical
photograph
887Surgical
Oncology
Radical Vaginectomy
(S11J17.3)BIOPSY/ CT
HPE, Operative notes, Post procedure clinical
photograph
888Surgical
OncologyRadical Vaginectomy + Reconstruction (S11J17.4) BIOPSY/ CT
HPE, Operative notes, Post procedure clinical
photograph
889Surgical
Oncology
Radical Hysterectomy
+Bilateral Pelvic Lymph Node Dissection (Bplnd) + Bilateral Salpingo
Ophorectomy (Bso) / Ovarian Transposition (S11J18.1)
BIOPSY, CTHPE, Operative notes, Post procedure clinical
photograph
890Surgical
OncologyAnterior Exenteration (S11J18.2) BIOPSY, CT
HPE, Operative notes, Post procedure clinical
photograph
891Surgical
OncologyPosterior Exenteration (S11J18.3) BIOPSY, CT
HPE, Operative notes, Post procedure clinical
photograph
892Surgical
OncologyTotal Pelvic Exenteration (S11J18.4) BIOPSY,CT
HPE, Operative notes, Post procedure clinical
photograph
893Surgical
OncologySupra Levator Exenteration (S11J18.5) BIOPSY,CT
HPE, Operative notes, Post procedure clinical
photograph
894Surgical
Oncology
Total Abdominal Hysterectomy(Tah) + Bilateral Salpingo Ophorectomy
(Bso) + Bilateral Pelvic Lymph Node Dissection (Bplnd) + Omentectomy
(S11J19.1)
CT, ENDOMETRIAL BIOPSYHPE, Operative notes, Post procedure clinical
photograph
895Surgical
OncologyChest Wall Resection (S11J20.1) BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
896Surgical
OncologyChest Wall Resection + Reconstruction (S11J20.2) BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
897Surgical
OncologyLimb Salvage Surgery Without Prosthesis (S11J22.1) BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
898Surgical
OncologyLimb Salvage Surgery With Custom Made Prosthesis (S11J22.2) BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
899Surgical
Oncology
Limb Salvage Surgery With
Modular Prosthesis (S11J22.3)BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
900Surgical
Oncology
Forequarter Amputation
(S11J22.4)BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
901Surgical
OncologyHemipelvectomy (S11J22.5) BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
902Surgical
Oncology
Internal Hemipelvectomy
(S11J22.6)BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
903Surgical
Oncology
Curettage & Bone Cement
(S11J22.7)
BIOPSY / OR CLINICO RADIOLOGICAL C/O
MALIGNANCY
HPE, Operative notes, Post procedure clinical
photograph
904Surgical
OncologyBone Resection (S11J22.8) BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
905Surgical
Oncology
Shoulder Girdle Resection
(S11J22.9)BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
906Surgical
OncologySacral Resection (S11J22.10) BIOPSY Final HPE
907Surgical
Oncology
Partial Nephrectomy
(S11J23.1)RADIOLOGICAL ONDE OF MALIGNANCY
HPE, Operative notes, Post procedure clinical
photograph
908Surgical
Oncology
Nephroureterectomy For Transitional Cell Carcinima Of Renal Pelvis
(S11J23.2)PATHOLOGY / URINE CYTOLOGY/ BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
909Surgical
Oncology
Radical Nephrectomy
(S11J23.3)RADIOLOGICAL ONDE OF MALIGNANCY
HPE, Operative notes, Post procedure clinical
photograph
910Surgical
OncologyEmasculation (S11J23.4) BIOPSY / IMAGING - CTSCAN OR MRI
HPE, Operative notes, Post procedure clinical
photograph
911Surgical
OncologyRadical Cystectomy (S11J23.5) BIOPSY, CT ABDO PELVIS
HPE, Operative notes, Post procedure clinical
photograph
912Surgical
OncologyOther Cystectomies (S11J23.6) BIOPSY, CT AFP
HPE, Operative notes, Post procedure clinical
photograph
913Surgical
OncologyTotal Penectomy (S11J23.7) BIOPSY /CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
914Surgical
OncologyPartial Penectomy (S11J23.8) BIOPSY / CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
915Surgical
Oncology
Inguinal Block Dissection One
Side (S11J23.9)CLINICAL PHOTOGRAPH/ BIOPSY/ FNAC
HPE, Operative notes, Post procedure clinical
photograph
916Surgical
Oncology
Radical Prostatectomy
(S11J23.10)IMAGING - MRI, BIOPSY / FLUNDE PET CT
HPE, Operative notes, Post procedure clinical
photograph
917Surgical
Oncology
High Orchidectomy
(S11J23.11)TUMOUR MARKERS, CT ABDO PELVIS
HPE, Operative notes, Post procedure clinical
photograph
918Surgical
Oncology
Bilateral Orchidectomy
(S11J23.12)BONESCAN, TUMOUR MARKER
HPE, Operative notes, Post procedure clinical
photograph
919Surgical
Oncology
Retro Peritoneal Lymph Node Dissection(RPLND) (For Residual Disease)
(S11J24.1)
CT ABDOMEN THORAX PELVIS, TUMOUR
MARKERS
HPE, Operative notes, Post procedure clinical
photograph
920Surgical
OncologyAdrenalectomy (S11J24.2)
IMAGING -CT, FDG PET CT, SERUM METARPHINES,
SERUM HORMETAMERPHINES, SERUM CORTIZOL
HPE, Operative notes, Post procedure clinical
photograph
921Surgical
OncologyUrinary Diversion (S11J24.3)
INMAGING TO SHOW EVIDENCE OF URINARY
OBSTRUCTION OR INVOLVEMENT OF LOWER
URINARY TRACT IN MALIGNANCY
HPE, Operative notes, Post procedure clinical
photograph
922Surgical
Oncology
Retro Peritoneal Lymph Node Dissection Rplnd As Part Of Staging
(S11J24.4)PATHOLOGY IF PRIMARY OR NODES, CT
HPE, Operative notes, Post procedure clinical
photograph
923Surgical
Oncology
Anterior Exenteration
(S11J25.1)Biospy, Cystoscopy, CT
HPE, Operative notes, Post procedure clinical
photograph
924Surgical
OncologyTotal Exenteration (S11J25.2) BIOPSY,CT
HPE, Operative notes, Post procedure clinical
photograph
925Surgical
Oncology
Bilateral Pelvic Lymph Node Dissection(BPLND) for CA Urinary Bladder
(S11J25.3)CT / PATHOLOGY OF PRIMARY
HPE, Operative notes, Post procedure clinical
photograph
926Surgical
Oncology
Mediastinal Tumour Resection
(S11J26.1)CECT THORAX, CT BX/ TUMOUR MARKER
HPE, Operative notes, Post procedure clinical
photograph
927Surgical
Oncology
Lung Metastatectomy. Solitary
(S11J27.1)CT THORAX
HPE, Operative notes, Post procedure clinical
photograph
928Surgical
OncologyLung Metastatectomy. Multiple (S11J27.2) CT THORAX
HPE, Operative notes, Post procedure clinical
photograph
929Surgical
Oncology
Sleeve Resection Of Lung
Cancer (S11J27.3)CT THORAX, BIOPSY/ CYTOLOGY
HPE, Operative notes, Post procedure clinical
photograph
930Surgical
Oncology
Lung Cancer Lobectomy
(S11J27.5)CT THORAX, BIOPSY/ CYTOLOGY
HPE, Operative notes, Post procedure clinical
photograph
931Surgical
Oncology
Lung Cancer Pnumenectomy
(S11J27.4)CT THORAX, BIOPSY/ CYTOLOGY
HPE, Operative notes, Post procedure clinical
photograph
932Surgical
Oncology
Lung Cancer Decortication
(S11J27.6)CT THORAX, BIOPSY/ CYTOLOGY
HPE, Operative notes, Post procedure clinical
photograph
933Surgical
OncologyOesophagectomy With Two Field Lymphadenectomy (S11J28.1) CT THORAX, ENDOSCOPY, BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
934Surgical
OncologyOesophagectomy With Three Field Lymphadenectomy (S11J28.2) CT THORAX, ENDOSCOPY, BIOPSY
HPE, Operative notes, Post procedure clinical
photograph
935Surgical
OncologyTracheostomy(S11J29.1) CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
936Surgical
OncologySubsternal Bypass (S11J29.2) Clinical indications
HPE, Operative notes, Post procedure clinical
photograph
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)
Sr.
No.Category Name of the Disease / Surgery
Mandatory documents at the time
of Preauth
Mandatory documents at
the time of Claim
937Surgical
Oncology
Ileotransverse Colostomy
(S11J29.10)CLINICAL PHOTOGRAPH, Biopsy
HPE, Operative notes, Post procedure clinical
photograph
938Surgical
OncologyGastro Jejunostomy (S11J29.9) CLINICAL PHOTOGRAPH, Biopsy
HPE, Operative notes, Post procedure clinical
photograph
939Surgical
OncologyIntercostal Drainage(Icd) (S11J29.8) CLINICAL PHOTOGRAPH, Biopsy
HPE, Operative notes, Post procedure clinical
photograph
940Surgical
Oncology
Suprapubic Cystostomy
(S11J29.7)Clinical indications
HPE, Operative notes, Post procedure clinical
photograph
941Surgical
OncologyColostomy(S11J29.6) CLINICAL PHOTOGRAPH, Biopsy
HPE, Operative notes, Post procedure clinical
photograph
942Surgical
OncologyIleostomy(S11J29.5) CLINICAL PHOTOGRAPH, Biopsy
HPE, Operative notes, Post procedure clinical
photograph
943Surgical
OncologyJejunostomy (S11J29.4) CLINICAL PHOTOGRAPH, Biopsy
HPE, Operative notes, Post procedure clinical
photograph
944Surgical
OncologyGastrostomy(S11J29.3) CLINICAL PHOTOGRAPH, Biopsy
HPE, Operative notes, Post procedure clinical
photograph
945Surgical
Oncology
Myocutaneous / Cutaneous
Flap (S11J30.1)
Clinical indications, Clinical
Photograph
HPE, Operative notes, Post procedure clinical
photograph
946Surgical
Oncology
Micro Vascular Reconstruction
(S11J30.2)
Clinical indications, Clinical
Photograph
HPE, Operative notes, Post procedure clinical
photograph
947Surgical
Oncology
Hysterectomy for Tumour
(S11J31.1)BIOPSY /ENDOSCOPY, USG/CT
HPE, Operative notes, Post procedure clinical
photograph
948Surgical
Oncology
Radical Hysterectomy for
Tumour (S11J31.2)BIOPSY /ENDOSCOPY, USG/CT
HPE, Operative notes, Post procedure clinical
photograph
949Surgical
Oncology
Surgery For Ca Ovary Early
Stage (S11J31.3)BIOPSY /ENDOSCOPY, USG/CT
HPE, Operative notes, Post procedure clinical
photograph
950Surgical
Oncology
Surgery For Ca Ovary Advance
Stage(S11J31.4)BIOPSY /ENDOSCOPY, USG/CT
HPE, Operative notes, Post procedure clinical
photograph
951Surgical
OncologyVulvectomy (S11J31.5) BIOPSY /ENDOSCOPY, USG/CT
HPE, Operative notes, Post procedure clinical
photograph
952Surgical
Oncology
Salpino Oophorectomy
(S11J31.6)BIOPSY /ENDOSCOPY, USG/CT
HPE, Operative notes, Post procedure clinical
photograph
953Surgical
OncologyLumpectomy(S11J32.4) BIOPSY, Clinical Photograph
HPE, Operative notes, Post procedure clinical
photograph
954Surgical
OncologyWide Excision(S11J32.3) BIOPSY, FNAC, Clinical Photograph, Mamography
HPE, Operative notes, Post procedure clinical
photograph
955Surgical
OncologyAxillary Dissection (S11J32.2) BIOPSY, FNAC, Clinical Photograph
HPE, Operative notes, Post procedure clinical
photograph
956Surgical
Oncology
Mastectomy Any Type
(S11J32.1)BIOPSY, FNAC, Clinical Photograph
HPE, Operative notes, Post procedure clinical
photograph
957Surgical
Oncology
Breast Reconstruction
(S11J32.5)BIOPSY, CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
958Surgical
Oncology
Chest Wall Resection
(S11J32.6)BIOPSY, CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
959Surgical
Oncology
Skin Tumours Wide Excision
(S11J33.1)BIOPSY, CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
960Surgical
OncologySkin Tumours Wide Excision + Reconstruction (S11J33.2) BIOPSY, CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
961Surgical
Oncology
Skin Tumours Amputation
(S11J33.3)BIOPSY, CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
962Surgical
OncologyAmputation (S11J34.3) BIOPSY, CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
963Surgical
OncologyWide Excision + Reconstruction (S11J34.2) BIOPSY, CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
964Surgical
OncologyWide Excision (S11J34.1) BIOPSY, CLINICAL PHOTOGRAPH
HPE, Operative notes, Post procedure clinical
photograph
965Surgical
OncologySurgical Correction Of Bronchoplural Fistula Thoracoplasty (S11J36.1) Xray/CT, Biopsy, Clinical indications
HPE, Operative notes, Post procedure clinical
photograph
966Surgical
OncologySurgical Correction Of Bronchoplural Fistula. Myoplasty (S11J36.2) Xray/CT, Biopsy, Clinical indications
HPE, Operative notes, Post procedure clinical
photograph
967Surgical
Oncology
Surgical Correction Of Bronchoplural Fistula Trans Plural BPF Closure
(S11J36.3)Xray/CT, Biopsy, Clinical indications
HPE, Operative notes, Post procedure clinical
photograph
968Surgical
Oncology
Marginal Mandibulectomy
(S11J37.1)
Biopsy,
radiological evidence Mandatory
HPE, Operative notes, Post procedure clinical
photograph
969Surgical
Oncology
Segmental Mandibulectomy
(S11J37.2)
Biopsy,
radiological evidence Mandatory
HPE, Operative notes, Post procedure clinical
photograph
970Surgical
OncologyTotal Glossectomy + Reconstruction (S11J37.3)
BIOPSY,
USG/Ct scan mandatory
HPE, Operative notes, Post procedure clinical
photograph
971Surgical
OncologyFull Thickness Buccal Mucosal Resection & Reconstruction (S11J37.4)
BIOPSY,
USG/Ct scan mandatory
HPE, Operative notes, Post procedure clinical
photograph
RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA SCHEME
Checklists for Mandatory Investigations / Documents for Preauthorisation Approvals and Claims settlement (13-03-2015)