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The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. What is covered: Click here to learn more about IEHP DualChoice. H8894_DSNP_23_3241532_M. IEHP DualChoice recognizes your dignity and right to privacy. This is called a referral. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. Your doctor or other provider can make the appeal for you. When we say existing relationship, it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in our plan. If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue. Our response will include our reasons for this answer. (Implementation Date: March 26, 2019). Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. a. You have a care team that you help put together. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. If you miss the deadline for a good reason, you may still appeal. ((Effective: December 7, 2016) You have the right to ask us for a copy of your case file. During this time, you must continue to get your medical care and prescription drugs through our plan. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. If your health requires it, ask us to give you a fast coverage decision If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. You can also visit https://www.hhs.gov/ocr/index.html for more information. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. You can contact the Office of the Ombudsman for assistance. The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patients cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options.