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QLM Protocol & Medical Guidelines Antenatal Care Guideline QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa © 2024-updated Version | ANC Protocol Updated.pdf |
GESTATION/ WEEK INVESTIGATION DESCRIPTION FREQUENCY COMMENTS Booking Visits 6-8 weeks Laboratory BHCG CBC Urine Dipstick Blood Group (ABO) FBS or RBS Syphilis serology (RPR) Hepatitis B & C Serology Rubella Ig G Toxoplasma Ig G & Ig M HIV1 Covered 11-14 Weeks U/S Laboratory Ultrasound Nuchal Translucency Urine Dipstick1 Covered 18-22 Weeks U/S Laboratory Ultrasound Anomaly Scan Urine Dipstick1 Covered 24 Weeks Laboratory Urine Dipstick OGTT 75 g Screening (24-28 Weeks)1 Covered 28-33 Weeks Laboratory CBC Urine Dipstick Hb & Rh-negative antibody Anti D for Rh negative 1stdose1 Covered 34-40 Weeks U/S Laboratory Ultrasound to assess fetal growth Urine Dipstick at 34,35,37,38,39,40 week Group B Streptococcal (GBS) at 35 wks. ' or anytime thereafter Anti D for Rh negative 2nddose (at 34 weeks)1 1 1 1Covered 41 Weeks U/S Laboratory Ultrasound & CTG in women who refuse induction of Labour Urine Dipstick1 Covered Prophylaxis & Supplements Folic Acid & Oral Iron. Vitamin D as a supplement from 2ndtrimester On Doctor's prescription/ monthly dispensed. Lab test not required. Covered based on medical necessity | ANC Protocol Updated.pdf |
This guideline for routine antenatal care / low risk pregnancy Reference : https://www. moph. gov. qa/english/Our Services/eservices/Pages/Clinical-Guidelines. aspx#A | ANC Protocol Updated.pdf |
QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa Jan 2024Obesity -Bariatric Procedures | Bariatric Surgery Guidelines.pdf |
❑ QLM cover the bariatric surgery and endoscopic procedures as an option for patients resistant to other non-surgical interventions and met the following criteria: Endoscopic Bariatric Procedures I. BMI ≥27 kg/m2 with obesity-related complications. II. BMI ≥30 kg/m2 without obesity-related complications III. BMI ≥40 kg/m2 when member prefer non-surgical management or if there is contaminated to surgery. Bariatric and Metabolic Surgical Procedures; I. BMI 30-34. 9 kg/m2 with uncontrollable type 2 diabetes. II. BMI 35-39. 9 kg/m2 with obesity-related complications. III. BMI ≥40 kg/m2 without obesity-related complication. If Member aged 12-18 years Bariatric surgery is covered if the following criteria met, 1. Mature adolescents in Tanner 4 or 5 pubertal development. 2. Severely obese patient. 3. The Pharmacological Intervention n showed no improvement after being taken at the prescribed full dosage for 6-12 months. | Bariatric Surgery Guidelines.pdf |
The following must be considered in members aged ≤18 Years: Underlying causes of obesity and co-morbidities should be treated first. Additional measurements to support the diagnosis of obesity. Report from Paediatric specialists or Paediatric Gastroenterologist and Dietitian are required along with surgeon report. ❑ For all age group, The following conditions/Treatment are not covered under Obesity unless it is mentioned in policy TOB ; 1. Investigations for obesity and its related conditions such as sleep apnea, Infertility,etc.. 2. Pharmacological treatment of obesity. 3. Management of Post-Operative Complications. 4. Bariatric Surgery for type 1 diabetic members with BMI < 40 For Coverage of the mentioned interventions Please refer to the policy table of benefits-TOB. Body Mass Index (BIA / In Body Chart) and detailed medical report/s are required for evaluation. Supporting report/s from specialist/s are required to evaluate the members with complications or co-morbidities. | Bariatric Surgery Guidelines.pdf |
References: https://www. moph. gov. qa/english/Our Services/eservices/Pages/Clinical-Guidelines. aspx https://www. uptodate. com/contents/bariatric-surgery-for-management-of-obesity-indications-and-preoperative-preparation?source=hi story_widget#H2963932 https://www. ncbi. nlm. nih. gov/books/NBK588750/ | Bariatric Surgery Guidelines.pdf |
QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa Dental Guidelines | Dental Guidelines 1.pdf |
Dental Guidelines Select the correct category (Dental Category) and tooth number (for applicable services) to prevent unnecessary denials. Services evaluation andapproval based onthe Core privileges (for General Dentist) &Non-core privileges (forcertified specialists) only asper QCHP guidelines. Services validation andapproval asper TOB ofpolicy such as crowns, prosthesis, polishing,implants, ortho treatment..etc. Periodicity for scaling /cleaning/polishing is based on the TOB of the policy. Filling services are approved with respective individual tooth number, multi quantity insingle service linenotacceptable (in both Pre-Approval/Registration and MDS ) inclaims submission. Upcoding such asusing adult treatment codes /tariff for PEDO treatment may result inpartial payment ofthesubmitted claims. Unbundling of services will not be considered such as Pulpotomy and filling billed for same tooth etc. Dental implants are covered only if mentioned in the TOB. Partial Denture isoneservice code for1 to7 teeth inno, as peragreed tariff. Orthodontic andalldental services periodicity consider the service date during theclaim submission. Orthodontic treatment is covered for the age of 12yrs to 25yrs or as mentioned in the TOB of the policy for the IOTN 4 and IOTN 5. www. qlm. com. qa 2 | Dental Guidelines 1.pdf |
Dental Guidelines Myofunctional Appliances coverable only Ifthepolicy mentions orthodontic treatment covered irrespective Iiof age or interceptive orthodontic treatment covered. Transparent & ceramic brackets and Invisalign or clear Aligners are not covered unless mentioned in the TOB of the policy. Cosmetic and Congenital services are not covered unless mentioned in the TOB of the policy. Habit breaking /space maintainers appliance coverage asperpolicy TOB, (ifpolicy covers preventive and interceptive orthodontic treatment ). Flexite /flexible dentures, broken /lost retainers, temporary fillings /temporary crown,micro implants,Desensitizing and laser procedure are not covered. Implant services must accompany a detailed dental report including the stages of services of implant and Operative notes along with supportive radiograph to be provided during claim submission. Gum treatments must accompany a detailed medical report by the treating physician clarifying the complain and type of Gum treatment done with teeth/ quadrant. Gum /Periodontal Treatment for more than 3 teeth requires detailed medical report, operative notes, pre- OPG and Periodontal chart-all sign and stamped by the treating Doctor. Gingivectomy for more than 2 teeth must accompany adetailed dental report, operative notes, pre and post treatment photos of the arch alone. Root Planning/ curettage services must accompany adetailed dental report,complete claim form,periodontal chart, and operative notes along with supportive radiograph to be provided during claim submission. www. qlm. com. qa 3 | Dental Guidelines 1.pdf |
Dental Guidelines Bone grafts andflap surgeries must accompany a detailed dental report,pre-service x-ray, periodontal chart, andoperative notes. Surgical and complicated extraction must accompany adetailed operative note and pre-service x ray. Orthodontics claims require Cephalogram, OPG, photos, Orthodontic assessment report based on cephalogram analysis, IOTN grade, treatment plan and visit record with patient signature. Please check thetable of Radiology requirement,page No 5 Post-procedural x-rays are part and parcel of dental treatment. Photos should cover only the working area not the member's face. Services involving multiple steps for the outcome of final treatment are considered as Part and Parcel services of the Final treatment and will not be billed to the QLM member. Part and parcel services mean that cannot be performed separately and shouldn't be billed to the member. Unagreed service to be updated before claims submission, failure to do so will result in claim denials. www. qlm. com. qa 4 | Dental Guidelines 1.pdf |
Service Description Pre-Service Post-Service Accepted Radiology Method Root Canal Treatment Yes Yes IOPA Complicated Extraction/Surgical extraction/Impacted /Embedded molars /Cysts of jaw Yes No IOPA or OPG Multiple restorations above 3 At a time, Interproximal caries, large carious lesions. No Yes OPG or IOPA Implants Yes Yes OPG Orthodontic treatment Yes No OPG, Cephalogram and photos Gum and periodontal treatments like Flap surgeries, Gingivoplasty, bone graft Yes No OPG TMJ disturbances Yes No OPG Crowns Yes Yes OPG or IOPA as per number of teeth involved Bridges Yes Yes OPG Dentures / prosthesis Yes Photo OPG or photo Radiology Requirement vs Procedure 5 | Dental Guidelines 1.pdf |
QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa Dental Protocol (Pre-Approval &Claims) | Dental Protocol 2.pdf |
Select the correct category (Dental Category) in Pre-Approval sub mission to prevent un-necessary denials. Crown cementation is the part and parcel of main procedure. Re-cementation is coverable only for old dislodged crowns. Partial Denture is one service code for 1 to 5 teeth in no,as per agreed tariff. Services evaluation and approval based on the Core privileges (for General Dentist) & Non-core privileges (for certified special ists) only as per QCHP guidelines. Services validation and approval as per TOB of policy such as prosthesis,polishing, ortho treatment,..etc. Filling services are approved with respective individual tooth number,multi quantity in single service line not acceptable ( in both Pre-Approval and MDS inclaims submission. Upcoding such as using adult treatment codes /tariff for PEDO treatment may will result in partial payment of the submitted c laims. Orthodontic and all dental services periodicity consider the service date during the claim submission not the approval date. Myofunctional Appliances coverable only If the policy cover orthodontic treatment covered irrespective of age. Habit breaking appliance coverage as per policy TOB,( if policy covers preventive treatment or orthodontic treatment without age restriction). Gum treatments must accompany a detailed medical report by the treating physician clarifying the complaint and Gum treatment done with teeth/ quadrant. | Dental Protocol 2.pdf |
Pre-procedure diagnostic x-ray showing the indication and post-procedure x-ray is mandatory in the following procedures: i. Root Canals ii. Crowns iii. Bridges iv. Dentures Pre-procedure diagnostic x-rays showing the indication is mandatory in the following procedures: i. Orthodontic (Cephalogram, OPG, visit record with patient signature and IOTN grade). ii. Prosthodontics. iii. Extractions and Surgical treatments. iv. Filling for more than 3 tooth. NB: Post-procedural x-rays are part and parcel of dental treatment. For Implant services : Detailed dental report and Operative notes along with supportive radiographs to be to be provided during claim submission. For Root Planning/ curettage services : Detailed dental report, complete claim form, periodontal chart, and operative notes along with supportive radiograph to be provided during claim submission. For Bone grafts and flap surgeries : Detailed report, periodontal chart, and operative notes. Unagreed service to be updated before claims submission, failure to do so will result in claims denials. For assistant mail : provider. management@qlm. com. qa | Dental Protocol 2.pdf |
Service Description Pre-Service Post-Service Accepted Radiology Method Root Canal Treatment Yes Yes IOPA Complicated Extraction/Surgical extraction/Impacted /Embedded molars Yes No IOPA or OPG Multiple restorations above 3 At a time,Interproximal caries, large carious lesions. No Yes OPG or Bitewings Implants Yes Yes OPG Orthodontic treatment Yes No OPG and Cephalogram Gum treatments like Flap surgeries, Gingivoplasty, Gingivectomy of multiple teeth etc Yes No OPG TMJ disturbances Yes No OPG Crowns No Yes OPG or IOPAR as per number of teeth involved Bridges No Yes OPG Dentures / prosthesis Yes Photo OPGDental Radiology Protocol *Gum /Periodontal Treatment for more than 3 teeth requires detailed medical report, operative notes, pre-OPG and Periodontal cha rt-all sign and stamped by the treating Doctor. * Post services x-ray will not be billed to QLM. | Dental Radiology 2.pdf |
Hypertension and Diabetes-Follow up QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa | getCustDocStreamForExtApp.pdf |
➢Initial investigations to diagnose Hypertension-HTN (confirmed High Blood Pressure measurement) are ; urine general, Serum cr eatinine, Lipid Profile, Fasting plasma glucose or Hb A1C (Hb A1C test if plasma glucose above the normal range or diabetic member). ➢Medical history and BP measurements to be clearly mentioned in the claim form. ➢QLM accept Lipid profile test ( mainly Cholesterol, LDL Cholesterol and Triglycerides as part from initial investigations fo r hypertensive and/or diabetic patients. ➢Triglyceride and LDL Cholesterol for follow up for those on lipid-modifying treatment, 3 months from starting treatment then annually. ➢CBC and Microalbuminuria not routinely recommended (Microalbuminuria coverable for diabetic members annually ). ➢Holter monitoring accepted in case of arrhythmias. ➢Follow up for stable Hypertensive and Diabetic members under regular medication as follow : Renal Function Test, Lipid Profile, Fasting Glucose and HA1C ( Annually ). HBA1C testing every 3 months as initial assessment and a part of ongoing management,then twice a year for members who have stable glycemic control. Other investigations, based on history and examination or if end organ damage and CVD suspected. Thyroid stimulating hormone testing based on history and examination for the initial assessment ( not routinely recommended ). Transaminase levels (alanine aminotransferase (ALT) and aspartate aminotransferase (AST) and creatine kinase before starting lipid-modifying treatment then annually if member on statin. Vit B12 testing annually for diabetic members on Metformin. | getCustDocStreamForExtApp.pdf |
References : Ministry of Public Health of Qatar-Clinical Guidelines https://www. moph. gov. qa/english/Our Services/eservices/Pages/Clinical-Guidelines. aspx#D Up To Date https://www. uptodate. com/contents/search Pub Med Visit Pub Med website athttps://www. ncbi. nlm. nih. gov Web MD Visit Web MD website at https://www. webmd. com | getCustDocStreamForExtApp.pdf |
Pentacam coverage Protocol QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa | Pentacam Coverage Protocol.pdf |
Pentacam coverable in following conditions: Corneal dystrophies covered unless genetic or congenital in origin. Refer to policy table of benefits for coverage. Complications of transplanted cornea, (if corneal transplant covered by the policy). Post-traumatic corneal scarring. pre-operative evaluation for intraocular lens power determination in cataract surgery. Pentacam not coverable in prenor post-operative corneal refraction surgery such as laser-assisted in-situ keratomileusis (LASIK) or photorefractive keratectomy (PRK), unless it is covered by the policy. Pentacam not coverable as routine refraction scans. | Pentacam Coverage Protocol.pdf |
Refences; Up To Date https://www. uptodate. com/contents/overview-of-contact-lenses?search=corneal%20topography&source=search_result&selected Title=2~15 0&usage_type=default&display_rank=2 https://www. uptodate. com/contents/search?search=corneal%20topography&sp=0&search Type=PLAIN_TEXT&source=USER_INPUT&search Contr ol=TOP_PULLDOWN&search Offset =1&auto Complete=false&language=&max=0&index=&auto Complete Term=&raw Sentence= Pub Med https://www. aao. org/eye-health/treatments/corneal-topography-4 American Academy of Ophthalmology https://www. ncbi. nlm. nih. gov/pmc/articles/PMC6778463/ | Pentacam Coverage Protocol.pdf |
Dupixent ➢Approved in severe cases of Atopic Dermatitis only if there is proven failure with other topical and systemic therapies or contraindications. ➢Specify level of severity aligned with POEM / SCORAD score result. ➢Atopic dermatitis lines of treatment: 1stline: topical corticosteroids 2ndline: Tacrolimus and Pimecrolimus 3rdline: systemic therapy ( Cyclosporine,Corticosteroids ) ➢Other Indications : 1. Chronic rhinosinusitis with nasal polyposis : Refractory cases The presence of eosinophilic granulomatosis if peripheral blood eosinophils >1500 cells/ micro L. 2. Moderate to severe eosinophilic asthma Peripheral blood eosinophils ≥150 cells/ mc L | PHARMACY - Dupixent Circular.pdf |
Dynastat 40mg Contains the active ingredient Parecoxib (COX-2 inhibitor). Indicated in the short-term management of pain. Adult dosage: maximum 80 mg per day. 3 days is the maximum period of treatment, if needed. | PHARMACY - Dynastat 40mg.pdf |
Fatty Liver Disease Diet and exercise to promote weight loss is the initial therapy. Pharmacological therapy is reserved for the following conditions only: 1. Weight loss failure. 2. Biopsy-proven NASH with fibrosis stage ≥ 2. 3. Biopsy-proven NASH with fibrosis stage ≥ 2 and diabetes. Diagnosis Treatment NASH but without diabetes Vitamin E 800 IU daily NASH and diabetes Metformin-1stline Pioglitazone-2ndline | PHARMACY - Fatty Liver Disease.pdf |
Iron Treatment with an iron preparation is justified only in the presence of a demonstrable iron-deficiency state. Oral formulations are indicated in iron deficiency w/o anaemia. ➢If there is poor absorption, consider Iron-Vitamin C combinations. ➢Reducing the dose frequency is a strategy to reduce GI side effects. Parenteral iron may be preferable in the following : 1. Severe anaemia (e. g. Hb <7g/d L). 2. Lack of response to oral iron after 2-4 weeks (Hb increase of <2g/d L). Iron supplements are not covered for patients who have had gastric surgery or procedures resulting in malabsorption of iron. | PHARMACY - Iron Supplements.pdf |
Migraine Severity, number of attacks, and onset date are required. NSAIDs and Triptans (e. g. Naramig ) are considered first-line therapy. CGRP antagonists ( e. g. Aimovig )are considered second line prophylactic agents. CGRP antagonists approval criteria : Acute (moderate to severe) cases: M ore than four headaches per month or headaches that last longer than 12 hours. Chronic Cases: headache for 15 or more days per month for more than three months, with the features of migraine headache present on at least eight days per month. 70mg or 140mg once per month. | PHARMACY - Migraine.pdf |
Ondansetron ➢Dopamine antagonists commonly used for nausea and vomiting are Metoclopramide and Domperidone. ➢Serotonin Antagonists (e. g. Ondansetron) approval criteria: 1. Considered as 1stline for nausea and vomiting associated with the following cases only: Chemotherapy Post-surgery 2. Considered as 2ndline for the following cases only : Hyperemesis Gravidarum (pregnancy-induced nausea). Gastroenteritis ( IV formulation only) | PHARMACY - Ondansetron.pdf |
Proton Pump Inhibitors (PPIs) Provide the onset date and frequency of GERD symptoms (intermittent/frequent). Specify the stage of GERD (mild, moderate, severe). Concomitant use of PPIs with NSAIDS or other is considered prophylactic unless proved to have a medical necessity. Follow step-up approach in mild cases and PPIs are not considered as first line treatment. Endoscopy is required for the diagnosis of peptic ulcer disease. The table below shows different cases and their initial approved durations of treatment : Case Approved Duration of Treatment GERD (Moderate to severe cases)and/or erosive esophagitis 8 weeks H. Pylori 10-14 days Duodenal Ulcer 4 weeks Gastric Ulcer 8 weeks | PHARMACY - PPI.pdf |
Repatha ➢Indicated in Homozygous Familial Hypercholesterolaemia and Mixed hyperlipidaemia (↑cholesterol and ↑ LDL) cases. ➢Continuous treatment for a minimum of 3 months prior to any modification in the sequence of (Statins, Ezetimibe, Repatha)respectively. ➢Approval criteria : 1. Full medical and family history. 2. Lipid profile LDL results remain ≥100mg/dl after treatment with maximum dose of statins and ezetimibe. LDL results remain ≥70mg/dl fo r very high risk atherosclerotic patients after treatment with maximum dose of statins and ezetimibe. | PHARMACY - Repatha.pdf |
Resolor Indicated for the treatment of chronic constipation only. Chronic constipation diagnosis is based upon the presence of symptoms for at least 3 months (with symptom onset at least 6 months prior to diagnosis). Considered as the final line of treatment if laxatives fail to provide relief. Dosing: Once daily for 4 weeks only, detect underlying cause for prolonged treatments. Iron-induced Constipation is treated by one of the following laxatives: 1. Senna (e. g. Agiolax, Senokot)-1stline 2. Bisacodyl (e. g. Dulcolax)-2ndline | PHARMACY - Resolor.pdf |
Topical Anti-Edematous Pain Relievers To enable smooth processing of topical anti-edematous pain relievers that contain the active ingredients (Aescin and Methyl Salicylate) such as Reparix Gel, Reparil Gel,etc... , please ensure to share the following: 1. Full diagnosis with detailed history as per below: Acute blunt trauma Sprains Strains Bruises with edema Edema due to chronic venous insufficiency 2. Onset date of the diagnosis i. e. the date of the first clinical symptom. 3. Cause of diagnosis if there is any (e. g. accident, post-surgery,... ). 4. Specify the treatment area(e. g. leg,arm,... ). 5. The requested daily dose and duration of treatment. | PHARMACY - Topical Anti-Edematous Pain Relievers.pdf |
Topical Anti-Edematous Pain Relievers Please take into consideration the following important points: Maximum approved duration of treatment is 7 days. Number of packets to be approved is shown in the example below: E. g. Apply to back twice daily for 7 days. 1 tube (50 grams) will be approved for the requested daily dose, frequency, and duration of treatment. | PHARMACY - Topical Anti-Edematous Pain Relievers.pdf |
Diabetes Mellitus (Type 2) G. P. prescriptions are accepted for newly-diagnosed patients in emergency cases and for 14 days only. Specialist referral is required in complicated cases. Metformin is considered first-line solely or in combination for all newly-diagnosed cases, if not, please provide the reason. Hb A1c result is required for every treatment modification for uncontrolled DM (every 3-6 months). GLP-1 agonists (e. g. Victoza, Ozempic, Rybelsus,Trulicity) approval criteria: Documented BMI score is a must. Approved for Hb A1c results ≥ 9% for newly diagnosed patients. Considered as initial therapy in patients with established ASCVD risk independent of A1c. | PHARMACY -Diabetes Mellitus Type 2.pdf |
Dry Eyes To enable smooth processing of dry eye cases, please ensure to share the following: 1. Ophthalmologist treating prescription. 2. Full specific diagnosis (e. g. If the patient is diagnosed with Conjunctivitis, please specify the type: Bacterial, Viral,,,,,, etc). 3. Full symptoms and complaints that are related to the diagnosis along with any past history of eye procedures. 4. The requested daily dose and duration of treatment. 5. Specify whether the patient wears any medical or non-medical (cosmetic) contact lenses. 6. Schirmer's Test results are required for long durations of treatment. | PHARMACY -Dry Eyes.pdf |
PHARMACY GUIDELINES ISSUED BY QLM LIFE & MEDICAL INSURANCE COMPANY QPSC LICENSED AND REGULATED BY QATAR CENTRAL BANK PREPARED BY : DR. CHRISTINA KHOURY christina. khoury@qlm. com. qa DATE: FEB. 2024 www. qlm. com. qa | PHARMACY GUIDELINES - FEB 2024.pdf |
ITEM INDICATION REMARKS Eye Lubricants Covered for 1 month only for acute conditions and 3 months for chronic conditions. 1 type of drops or gel Please dispense enough quantity according to the logic 1ml =20 drops not exceeding 2 MD bottles/month. Please dispense enough quantity for UD ampoules according to requested dosage and not exceeding 4 UD boxes / month. Max. quantity : 2 tubes per month Check for herbal treatment coverage. Normal Saline Nasal Sprays Acute Blepharitis / Bacterial Conjunctivitis/ Adenoviral Conjunctivitis if prescribed with other antibiotics / steroids/NSAIDs. Chronic Blepharitis/Meibomaianitis up to 6 months only. Corneal Scar Punctate Keratitis Corneal Ulcer Chronic Glaucoma if prescribed with other anti-glaucoma eye drops Post-surgical except for post-lasik Dry Eye Syndrome if with supporting documentation (TBUT/ FDDT) Edema, bruises, and inflammatory cases. URTI (i. e. sinusitis, rhinitis,... ) for 0-5 years old Post-Surgical for ages 6 and above. 1 bottle and 1 brand only Reparix/Reparil and all other agents having the active ingredients (Aescin and/or Methyl Salicylate) Gel Pharmacy Guidelines 2024 (Page 2) | PHARMACY GUIDELINES - FEB 2024.pdf |
Permixon, Prostenal BPH if prescribed with other medications for treatment only and not prophylaxis Check for herbal treatment coverage PPIs GERD / Duodenal ulcer / Peptic Ulcer H. PYLORI 2 months only if newly-diagnosed 2-3 weeks according to prescribed duration Prophylaxis with other NSAIDs / anti-biotics /... not covered Ondansetron Cancer chemotherapy Postoperative nausea/vomiting Hyperemesis Gravidarum (pregnancy-induced n/v) Gastroenteritis (IV formulation only)Acute conditions only. NSAID Gels All indicated cases Max. quantity : 2 tubes per month ITEM INDICATION REMARKS GLP-1 Agonists (Trulicity, Victoza, Ozempic, Rybelsus, Mounjaro)Saxenda and Wegovy are company exclusions. Not covered for obesity. Type 2 DM only No Hb A1c is required for members under treatment Hb A1c must be ≥ 9% for all newly-diagnosed Hb A1c must be > 7% if prescribed for the first time in addition to previous DM medications (uncontrolled diabetic patients) (Page 3) Pharmacy Guidelines 2024 | PHARMACY GUIDELINES - FEB 2024.pdf |
Pharmacy Guidelines 2024 (Page 4)Propolsaft Syrup Cough Check for herbal treatment coverage Take care that immuno boosters are a company exclusion. Omacor Hyperlipidemia (TGs 500 mg/ dl ( 5. 65 mmol/ l or higher)Covered for the shared policies only (Go to pg. 6) Mouthwashes Bepanthene Cream Pharyngitis and Tonsilitis Eczema and all indicated skin disorders Covered for Qatar Energy LNG only Nizoral, Clobex, Kenazole Shampoos Fungal infections and dermatitis. Medicated Shampoos are covered only. 1 bottle per month Oral Glucosamine Knee Osteoarthritis (Gonarthrosis) only Moderate to severe only with radiology report Covered for the shared policies only (Go to pg. 6) Tacrolimus and Pimecrolimus Atopic dermatitis and Eczema Check for immunotherapy coverage Legalon Forte Fatty Liver disease Check for herbal treatment coverage ITEM INDICATION REMARKS Activated charcoal (e. g. Eucarbon, Marny's Neocarbon)IBS, constipation, flatulence,... | PHARMACY GUIDELINES - FEB 2024.pdf |
Pharmacy Guidelines 2024 (Page 5)ITEM INDICATION REMARKS Cystone, Alka-Ur Kidney Stones and other indications as per the leaflet Treatment only not prophylaxis | PHARMACY GUIDELINES - FEB 2024.pdf |
Pharmacy Guidelines 2024 (Page 6)POLICY HOLDER Amiri Yacht Tadmur Holding Vodafone Qatar MOFA BEIN Media Group YES YES YES YES YESYES YES YES YES YESOMACOR COVERAGE GLUCOSAMINE COVERAGE YES YESQatar Central Bank Qataris/Non-Qataris Gulf Warehousing Company Premier A | Premier B | Advantage C QNB Qatar Energy LNG Qatar Energy YES YES YESYES NO NO NOYES | PHARMACY GUIDELINES - FEB 2024.pdf |
QLMPre-Authorization Requirements for The Common In-Patient (IP) & Outpatient (OP) Procedures | Pre-Authorization Requirements.pdf |
QLMIn-Patient (IP) Procedures A. Nasal surgery ( Septoplasty, FESS, SMD). B. Cholecystectomy. C. Joints ligament or tendon tear repair surgery ( ACL, meniscus repair... ). D. Tonsillectomy, Adenoidectomy and Myringotomy. E. Renal stone Procedures. F. Hernia repair. | Pre-Authorization Requirements.pdf |
QLMNasal surgery (Septoplasty, FESS, SMD) ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the detail s of conservative treatment and past surgical-history. N. B: Frequency of Sinusitis attacks in last year is required to facilitate evaluation of FESS cases. ➢Etiology of Deviated Nasal Septum (DNS) : ➢In the event of nasal trauma, please provide a comprehensive history of the incident (how, where, and when it occurred). If t he trauma is associated with a specific sport, please specify the name of the sport,and whether it is professional or not.. ➢Provide an endoscopy report or a CT scan report (For indicated cases). *preferably computerised Reports. | Pre-Authorization Requirements.pdf |
QLMCholecystectomy ➢Medical report including all manifestations (symptoms and signs) details and duration along with the frequency of biliary col ic attacks in the previous month. ➢Ultrasound Report. ➢Verify the presence of history of bariatric surgery. In cases where applicable, then detailed history required such as date o f the surgery,post-operative complications,etc. | Pre-Authorization Requirements.pdf |
QLMJoints, ligaments or tendons tears repair surgery ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the details of cons ervative treatment,if applicable and past surgical-history. ➢Confirm if there is history of trauma, In the event of trauma, please provide a comprehensive history of the incident, detailing how, where, and when it occurred. If the trauma is associated with a specific sport, specify the name of the sport and whether it is prof essional or not. ➢Additionally, indicate whether the incident is work-related. ➢Radiology report/s. N. B : If physiotherapy is done as a part of the conservative treatment, then please share progress report along with the atte ndance sheet for the provided sessions. | Pre-Authorization Requirements.pdf |
QLMTonsillectomy, Adenoidectomy and Myringotomy ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the details of cons ervative treatment and past surgical history. ➢Frequency of tonsilitis attacks per year, frequency of otitis media attacks & degree of tonsillar enlargement. ➢Endoscopy report is required for further evaluation ➢Tympanogram for Myringotomy Procedures. | Pre-Authorization Requirements.pdf |
QLMRenal stone removal ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the details of cons ervative treatment and past-history of surgeries. ➢Radiology report. ➢Verify the presence of a history of bariatric surgery, along with the date of the surgery and post-operative complications,if a ny. | Pre-Authorization Requirements.pdf |
QLMHernia Repair ➢Medical report including all manifestations (symptoms and signs) with its details, duration and past surgical history. ➢Radiology report/s,( In case of inguinal hernia repair please specify the type of Hernia whether it is direct or indirect). | Pre-Authorization Requirements.pdf |
QLMAdmission and admission extension ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with plan of treatment a nd past-history of surgeries. ➢Submission of Supporting Reports such as labs investigations and radiology reports,etc. Documents required for extension evaluation: ➢ Updated medical report stating the reason of extension. ➢Vital signs chart, updated lab result, and radiology reports. | Pre-Authorization Requirements.pdf |
QLMOutpatient procedures (OP) A. Oesophago-Gastro-Duodenoscopy (OGD) B. Colonoscopy C. Epidural injection D. Intra-articula r Injection E. Skin lesion Removal | Pre-Authorization Requirements.pdf |
QLMOesophago-Gastro-Duodenoscopy ➢Medical report including all manifestations (symptoms and signs),illness duration,the provided conservative treatment and p ast surgical history. ➢Verify if the member on Proton Pump Inhibitor-(PPI) Medication, In cases where applicable, kindly provide the medication name, duration and dosage. ➢Verify the presence of a history of bariatric surgery, along with the date of the surgery and post-operative complications,if a ny. | Pre-Authorization Requirements.pdf |
QLMColonoscopy ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the details of cons ervative treatment and past-surgical history. ➢Supporting reports such as Laboratory Reports (e. g CBC, Stool /Analysis or occult blood stool),previous histopathology report ,etc. ➢Calprotectin if IBD suspected. | Pre-Authorization Requirements.pdf |
QLMEpidural injection ➢Medical report including all manifestations (symptoms and signs),duration, details of conservative treatment and past-history of surgeries. ➢Details of initial conservative treatment ( oral medications, physiotherapy sessions & etc.. ) with progress report from phy siotherapist. ➢Radiology report/s. | Pre-Authorization Requirements.pdf |
QLMIntra-Articular injection ➢Medical report including details of symptoms and signs along with details of conservative treatment. ➢Radiology report. ➢Name of medication will be injected. ➢Details of the initial conservative treatment done for same illness. | Pre-Authorization Requirements.pdf |
QLMSkin lesions Procedures ➢Medical report including diagnosis, etiology,duration and necessity of requested procedure. ➢Radiology report for applicable cases. | Pre-Authorization Requirements.pdf |
OP QLMOutpatient laboratory services ➢Claim form including symptoms and signs,illness duration along with the past-medical history. ➢Preliminary investigations results are required for evaluation for the secondary/ additional requested investigations. | Pre-Authorization Requirements.pdf |
QLM Protocol & Medical Guidelines © 2022-2023 1 QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa | QLM Protocol Medical Guidelines 1.pdf |
TABLE OF CONENTS 1. General Prior-Authorization & Claims Guidance.................................................................................................. 3 2. Coverage of VITAMIN D Test.................................................................................................................................... 4 3. Hypertension-Diabetes-Dyslipidemia follow up............................................................................................... 5 4. Thyroid Dysfunction-Initial Investigations & Follow up....................................................................................... 7 5. CT Scan for Abdominal pain in the Emergency Department................................................................................ 8 6. Helicobacter pylori infection.................................................................................................................................... 9 7. Upper Gastrointestinal Endoscopy and Colonoscopy........................................................................................... 10 2 | QLM Protocol Medical Guidelines 1.pdf |
General Prior-Authorization & Claims Guidance Allrequested investigations and services aresubject toresult ofthepre-liminary investigations results and policies TOB coverage. Wrong selection ofservice category inpre-approval submission willresult inservice denial inclaims. Physiotherapy and Vaccination services must besubmitted under corresponding categories forpre-approval (excluding consultation asnoauthorization required ),unless thefacility is APIintegrated then consultation tobe pushed separately (general category) forapproval. Crown cementation isthepart and parcel ofmain procedure. Re-cementation isapproved only forolddislodged crowns. Partial Denture isone service code for1to5teeth inno,asperagreed tariff. Services evaluation and approval based onthe Core privileges (for General Dentist) &Non-core privileges (for certified specialists) only asper QCHP guidelines. Services validation and approval asper TOB ofpolicy such asprosthesis,polishing,ortho treatment,...... Filling services areapproved with respective individual tooth #multi quantity insingle service line notacceptable. Upcoding such asusing adult treatment codes /tariff for PEDO treatment may willresult inpartial payment ofthe submitted claims. Unagreed service tobeupdated before claims submission, failure todosowillresult inclaims denials. Forassistant mail :provider. management@qlm. com. qa Photochromic /Transitional lenses notcoverable norpayable inclaims. Forclaims submission upload thecorrect updated MDS format (available intheportal ). 3 | QLM Protocol Medical Guidelines 1.pdf |
4Routine blood screening forvitamin Ddeficiency isnotrecommended inindividuals who arenotatriskand inthe absence ofspecific clinical concerns. Coverable inhighly suspected patients with indicated symptoms such asmetabolic bone diseases. Test canberepeated after sixmonths ofcontinuous regular treatment fordeficiency cases. Vit Dsupplementation Forpregnant women canbeprescribed by Obstetrician with outlaboratory test. Supplement forbreastfed infants notcovered unless itismentioned inthepolicy TOB (table ofbenefits). Allrequests for Vit DMedication should besupported bylabtest report/ MDS investigation result field forclaims settlement. Which iscovered fordeficient cases only. Coverage of VITAMIN D Test | QLM Protocol Medical Guidelines 1.pdf |
Initial investigations todiagnose Hypertension-HTN (confirmed High Blood Pressure measurement) are;urine general,Serum creatinine,Lipid Profile,Fasting plasma glucose or Hb A 1C(Hb A 1Ctest ifplasma glucose above the normal range ordiabetic member). Medical history and BPmeasurements tobeclearly mentioned intheclaim form. QLM accept Lipid profile test (mainly Cholesterol, LDL Cholesterol and Triglycerides aspart from initial investigations forhypertensive and/or diabetic patients. Triglyceride and LDL Cholesterol forfollow upforthose onlipid-modifying treatment, 3months from starting treatment then annually. CBC and Microalbuminuria not routinely recommended (Microalbuminuria coverable for diabetic member annually). Holter monitoring accepted incase ofarrhythmias. Follow upforstable Hypertensive and Diabetic members under regular medication asfollow : Serum creatinine,Lipid Profile (Triglyceride and LDLCholesterol),Fasting Glucose or/HA1C(Annually) HBA 1Ctesting every 3months atinitial assessment and aspart ofongoing management then twice ayear for members who have stable glycaemic control. Other investigations, based onhistory and examination orifend organ damage and CVD suspected. 5Hypertension-Diabetes-Dyslipidemia follow up | QLM Protocol Medical Guidelines 1.pdf |
Thyroid stimulating hormone testing based on history and examination for the initial assessment ( not routinely recommended). Transaminase levels (alanine aminotransferase (ALT) and aspartate aminotransferase (AST) and creatine kinase before starting lipid-modifying treatment then annually if member on statin. Vit B12 testing annually for diabetic members on Metformin. 6Hypertension-Diabetes-Dyslipidemia follow up | QLM Protocol Medical Guidelines 1.pdf |
Forsymptomatic members TSH only iscoverable and canbefollowed by T4&T3ifitresults isbelow thenormal range or T4only ifitisabove thereference range. Fortreatment adjustment only TSH iscoverable three month after treatment then Biannually /orannually for euthyroid status. Antithyroid Antibodies (such as Anti-Thyroid Peroxidase Antibodies )coverable once forthesuggestive patients, repeated positive test notcoverable. Thyroid ultrasound scanning coverable ifclinically indicated (NOT routinely recommended). 7Thyroid Dysfunction-Initial Investigations & Follow up | QLM Protocol Medical Guidelines 1.pdf |
Ifthehistory and physical examination failed todiagnose thecase then further investigations willbeapproved based ondoctor evaluation ofthe Pain acuity, duration, intensity,......etc. aswell aspatient age and gender in thebelow sequences ; Laboratory tests Plain radiographs (ifbowel obstruction, bowel perforation, oraradiopaque foreign body issuspected) Ultrasound Finally, computed tomography (CT) only after anegative orinconclusive preliminary investigations. CTscan canbeapproved aspreliminary investigation forconditions require immediate surgical intervention as perthedoctor evaluation. 8CT Scan for Abdominal pain in the Emergency Department | QLM Protocol Medical Guidelines 1.pdf |
Testing for Helicobacter pylori (H. pylori ) coverable; If the clinician plans to offer treatment for positive results or After Completion of treatment for documented H. pylori infection in order to confirm eradication. Serology not coverable for above mentioned conditions Endoscopic testing coverable if there is an alarm feature only screening test not coverable. Ultrasound for H-pylori cases consider as screening which is not coverable 9Helicobacter pylori infection | QLM Protocol Medical Guidelines 1.pdf |
Endoscopy not coverable forscreening purposes/ orsurveillance orifrelated touncovered disease asper policy table ofbenefits (TOB). Colonoscopy not covered for Screening/surveillance,such asscreening for Colon polyp orcancer, or Inflammatory bowel disease unless thebenefit covered bypolicy. Not recommended torequest both upper GIendoscopy &colonoscopy inone setting unless there isamedical necessity todoboth. Upcoding may willresult inpartial payment ofthesubmitted claims. 10Upper Gastrointestinal Endoscopy and Colonoscopy | QLM Protocol Medical Guidelines 1.pdf |
References : Ministry of Public Health of Qatar-Clinical Guidelines https://www. moph. gov. qa/english/Our Services/eservices/Pages/Clinical-Guidelines. aspx Up To Date https://www. uptodate. com/contents/search Pub Med Visit Pub Med website athttps://www. ncbi. nlm. nih. gov Web MD Visit Web MD website at https://www. webmd. com 11 | QLM Protocol Medical Guidelines 1.pdf |
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