Clinical Determinations and Indications Library
Below is a list of published Clinical Determinations and Indications (CDI) community providers may use as a resource to help determine if a Veteran meets VA clinical criteria for services and procedures delivered in the community.
NOTE: While these CDIs are intended for community providers, VA providers and staff should use them as a reference when determining clinical appropriateness for Veterans to receive a specific service in the community.
Search Instructions
If you are unable to find the CDI you are looking for, please use the VA search function to search for keywords related to the appropriate medical policy.
Use of this content indicates your agreement and acceptance to the terms and conditions listed in the Agreement to Access Library of Clinical Determinations and Indications.
View Agreement to Access Library of Clinical Determinations and Indications
Clinical Determinations and Indications listed by categories of care
Audiology / ENT / Sleep Medicine / Pulmonology
Cardiology / Cardiothoracic Surgery
Durable Medical Equipment (DME)
Gastroenterology / Urology
Mental Health / Behavioral Health
Neurology / Neurosurgery
Nuclear Medicine / Oncology / Radiation Oncology
Ophthalmology / Optometry
Orthopedics / Podiatry / Amputation
Pain Management / Physical Medicine & Rehabilitation (PM&R)
Surgery
Women’s Health / Gynecology / Obstetrics
Terms and Definitions
Each clinical determination and indication contains the following terms and associated definitions:
- Effective date: Date the community care medical policy is effective.
- Exclusion criteria: Characteristics that disqualify prospective Veterans from care pathways or prescriptions.
- Experimental or Investigational: A treatment, procedure, equipment, drug, or service that has not been determined to be medically effective for the condition being treated but may be part of a research study to evaluate if the condition improves with use.
- Facility: The service is performed in a facility setting (i.e., hospital, ambulatory or surgical center).
- Facility type: Hospital or other institution where outpatient and inpatient services are performed.
- FDA approval: To receive U.S. Food and Drug Administration (FDA) approval, drug manufacturers must conduct testing and submit their data to FDA. FDA may approve the drug if the agency determines the benefits of the drug outweigh the risks for intended use.
- Locality description: Place of service locality (e.g., city, county).
- Medical necessity: Health care services that can be justified as reasonable, necessary and appropriate based on evidence-based clinical standards of care.
- Medicare carrier: Identification number assigned by Centers of Medicare and Medicaid Services (CMS) to a carrier (Medicare Administrative Contractor) authorized to process claims from a physician or supplier.
- Medicare locality: Identification number assigned by the CMS for a locality where care is received.
- Non-facility: The service is performed in a non-facility setting (i.e., physician’s office or outpatient clinic).
- Policy number: A unique ID code that combines an abbreviation of the name and version number.
- Procedure: Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) codes are industry standard codes used to identify specific surgical, medical, or diagnostic interventions.
- Procedure code modifier: Supplemental information or “adjust care” descriptions to provide extra detail concerning a procedure or service.
Contacts
Questions?
Complete the form below to submit a question about a published CDI to the IVC Clinical Determinations Unit (CDU).
Note: This process is not to be used to submit a Request for Service (RFS), Form 10-10172. Instructions for the RFS process are on the Care Coordination Overview page.
