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 End User Agreement to Access Library of Clinical Determinations and Indications.
End User 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
Complementary & Integrative Health (CIH)
Dermatology
Diagnostics / Imaging
Durable Medical Equipment (DME)
Endocrinology
Gastroenterology / Urology
- Computed Tomography (CT) Colonography / Virtual Colonoscopy
- Fecal Microbiota Products for Clostridioides difficile Infections
- Intragastric Balloon
- Metabolic and Bariatric Surgery
- Prostate-Specific Membrane Antigen Positron Emission Tomography Scan for Prostate Cancer
- Routine Colorectal Cancer Screening
- Sacral Neuromodulation
- Transurethral Water Vapor Thermal Therapy for Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia
- Transurethral Waterjet Ablation for Benign Prostatic Hyperplasia
Miscellaneous
Mental Health / Behavioral Health
Neurology / Neurosurgery
Nuclear Medicine / Oncology / Radiation Oncology
- Intensity Modulated Radiation Therapy Using Photons
- Lutetium-177 (Lu177) PSMA-617, Vipivotide Tetraxetan (Pluvicto)
- Low-Dose CT Scan for Lung Cancer Screening
- Prostate-Specific Membrane Antigen Positron Emission Tomography Scan for Prostate Cancer
- Proton Beam Therapy
- Tumor Treating Fields (TTFs) Therapy
Ophthalmology / Optometry
Orthopedics / Podiatry / Amputation
- Allograft Injection for Degenerative Disc Disease
- Dextrose Prolotherapy for Musculoskeletal Pain
- Discseel (Fibrin Sealant Injection)
- Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
- Minimally Invasive and Open Sacroiliac Joint Fusion / Stabilization
- Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA) Implant System for Transfemoral Amputations
- Spinal Fusion Surgery
- Total/Partial Knee Arthroplasty
Pain Management / Physical Medicine & Rehabilitation (PM&R)
- Allograft Injection for Degenerative Disc Disease
- Bioimpedance Devices for Detection of Lymphedema
- Dextrose Prolotherapy for Musculoskeletal Pain
- Discseel (Fibrin Sealant Injection)
- Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
- Ketamine for Chronic Pain
- Medical Massage Therapy
- Pneumatic Compression Devices for Lymphedema
- Spinal Fusion Surgery
Pharmacy
Surgery
- Allograft Injection for Degenerative Disc Disease
- Autologous Chondrocyte Implantation
- Balloon Sinuplasty
- Bioimpedance Devices for Detection of Lymphedema
- Corneal Collagen Cross-Linking
- Cryoablation for Malignant Breast Tumors
- Functional Endoscopic Sinus Surgery (FESS)
- Intragastric Balloon
- Metabolic and Bariatric Surgery
- Micro-Invasive Glaucoma Surgery
- Minimally Invasive and Open Sacroiliac Joint Fusion / Stabilization
- Mitral Valve Transcatheter Edge-to-Edge Repair
- Sacral Neuromodulation
- Spinal Fusion Surgery
- Thread Carpal Tunnel Release
- Total Artificial Heart
- Total/Partial Knee Arthroplasty
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 concerning published Clinical Determinations and Indications can be emailed to the IVC Clinical Determinations Unit by submitting a completed Clinical Determinations and Indications Question Submission Form, VA Form 10-322.
IVC Clinical Determination Unit
(VHA16IVCClinicalDeterminationUnit@va.gov)
NOTE: This email should only be used to submit a completed VA Form 10-322. It is not monitored otherwise.
Resources
Instructions for submitting Request for Service (RFS), VA Form 10-10172, can be found on the Care Coordination Overview page. Please follow the instructions on that page to ensure Veteran’s RFS forms are received by the appropriate VA medical center for processing to prevent delays in Veterans receiving the care needed.
