Rule Category:

Medical

` Ref: No:
2012-MN-0017

Version Control:
Version No. 3.0

Effective Date:
June-2012

Revision Date:
August-2015

Daycare Procedures

Adjudication Rule
Table of content
Abstract Scope Adjudication Policy Adjudication examples Denial codes Appendices
Page 1 Page 2 Page 2 Page 3 Page 3 Page 4

Approved by:
Daman
Abstract
Responsible:
Medical Strategy &
For Members Development Department

Surgeries listed by Daman as day care procedure are minor surgeries or investigations. Related Adjudication Rules:
Day care admission can be extended to inpatient stay if the patient presents with a None
need for prolonged medical care or any medical emergency within the stay.
Daman covers day care procedures for all its health insurance plans, subject to policy
terms and conditions. Disclaimer
By accessing these Daman Adjudication Rules
(the “AR”), you acknowledge that you have read
and understood the terms of use set out in the
For Medical Professionals disclaimer below:
The information contained in this AR is intended
to outline the procedures of adjudication of
Daman covers day care procedures for all its health insurance plans, subject to policy medical claims as applied by the National Health
Insurance Company – Daman PJSC (hereinafter
terms and conditions. “Daman”). The AR is not intended to be
comprehensive, should not be used as treatment
Day care procedure includes a number of relatively minor procedures. While considering guidelines and should only be used for the
purpose of reference or guidance for adjudication
day surgery, the treating doctor has to document the fitness of the patient for day procedures and shall not be construed as
surgery. Daman does not restrict any procedure based on the type of anesthesia. Day conclusive. Daman in no way interferes with the
treatment of patient and will not bear any
care procedures can be performed under General anesthesia, regional anesthesia or responsibility for treatment decisions interpreted
through Daman AR. Treatment of patient is and
under Local anesthesia. Appropriate anesthetic drug selection is vital for day surgery to remains at all times the sole responsibility of the
be performed efficiently. treating Healthcare Provider. This AR does not
grant any rights or impose obligations on Daman.
The AR and all of the information it contains are
Any procedure can be performed on day care basis when decided by the treating doctor provided "as is" without warranties of any kind,
and medically justified. whether express or implied which are hereby
expressly disclaimed.
Under no circumstances will Daman be liable to
Daman covers IP stay or IP extensions of the day stay for any day care procedures any person or business entity for any direct,
indirect, special, incidental, consequential, or
when medically necessary. other damages arising out of any use of, access
to, or inability to use or access to, or reliance on
this AR, including but without limitation to, any
loss of profits, business interruption, or loss of
programs or information, even if Daman has been
specifically advised of the possibility of such
damages. Daman also disclaims all liability for
any material contained in other websites linked to
Daman website.
This AR is subject to the laws, decrees, circulars
and regulations of Abu Dhabi and UAE. Any
information provided herein is general and is not
intended to replace or supersede any laws or
regulations related to the AR as enforced in the
UAE issued by any governmental entity or
regulatory authority, or any other written
document governing the relationship between
Daman and its contracting parties.
This AR is developed by Daman and is the
property of Daman and may not be copied,
reproduced, distributed or displayed by any third
party without Daman‟s express written consent.
This AR incorporates the Current Procedural
Terminology and Current Dental Terminology
(CPT® and CDT®, which is a registered
trademark of the American Medical Association
(“AMA”), and the American Dental Association
(“ADA”) respectively), and the CPT and CDT codes
and descriptions belong to the AMA. Daman
reserves the right to modify, alter, amend or
obsolete the AR at any time by providing one
month prior notice.

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Daycare Procedures

Scope Column A Column B

The scope of this adjudication rule is to enlist the Acute / Sub-acute Continuous or intermittent
procedures that can be performed on Day care bleeding and / or intravenous medication and /
basis. Moreover, this adjudication rule explains the intervention requiring or infusion (does not includes
circumstances where day care cases can proceed to Haemoglobin drop. feeding through gastric tube).
inpatient stay.
Surgery, intervention or
Blood pressure Systolic
Daman considers this as an advisory document. It special diagnostic measure
< 90 or > 200 mmHg
does not restrict the treating doctor if inpatient within the next 24 hours, the
Diastolic <60 or >120
special Resources and facilities
admission is medically justified. mmHg.
of a hospital requires.
Day care procedure includes a number of relatively
Acute / (progressive) Multiple monitoring of vital
minor procedures. Surgeries listed by Daman as
Paralysis or other signs, including through the
day care procedure are minor surgeries or acute neurological monitor, at least every 4
investigations. Symptoms. hours.
Daman segregates Day care procedures based on Severe electrolyte
the following criteria: Treatment in an intensive care
imbalance or blood gas
Intermittent, several times
derailment or current
 Minimal physiological trespass. derailment urinary
daily, or continuous, assisted
or controlled ventilation.
 Not associated with excessive blood loss or metabolites.
fluid shifts. Life-threatening
 Very low risk of serious post-operative infection or persistent Sudden disturbance of
or intermittent Fever consciousness or acute
complications (e.g.: bleeding or airway
(> 38.0 ° C core confusional state.
obstruction). temperature).
 Duration of procedure up to 1 hour or 2
Pulse rate < 50/min or >
hours maximum. Acute hearing loss.
140/min.
 Post-operative pain controllable with oral Blood pressure Systolic < 90
analgesics after discharge. or > 200 mmHg Diastolic <60
 Acute or progressive
sensory, motor, or >120 mmHg.
 The patient reasonably ambulant at the time
of discharge. functional, circulatory
or respiratory or Acute Loss of vision or sense
dermatologic of balance.
disturbances as well as Acute hearing loss.
pain conditions, which
Adjudication Policy obstruct or endanger Acute / (progressive) Paralysis
the patient seriously. or other acute neurological
Eligibility / Coverage Criteria Symptoms.

Daman covers day care procedures for all health Life-threatening infection or
insurance plans administered by Daman (subject to persistent or intermittent
policy terms and conditions). Fever (> 38.0 ° C)
 Disease, treatment
While considering day surgery, the treating doctor with cancer Acute / Sub-acute bleeding
has to document the fitness of the patient for day chemotherapy or other and / or intervention requiring
potentially life- Hemoglobin drop.
surgery. Daman does not restrict any procedure
threatening
based on the type of anesthesia. Day care Substances requires. Severe electrolyte imbalance
procedures can be performed under General or blood gas derailment or
anesthesia, regional anesthesia or under Local current derailment urinary
anesthesia. Appropriate anesthetic drug selection is metabolites.
vital for day surgery to be performed efficiently.
Continuous or
Acute or progressive sensory,
Any procedure can be performed on day care basis intermittent
motor, functional, circulatory
when decided by the treating doctor and medically intravenous
or respiratory or dermatologic
medication and / or
justified. disturbances as well as pain
infusion (does not
conditions, which obstruct or
Daman covers IP stay or IP extensions of the day includes feeding
endanger the patient seriously
stay for any day care procedures when medically through gastric tube).
necessary. Pulse rate < 50/min or Strong suspicion or evidence
> 140/min. of myocardial Ischemia
Day care admission can be extended to inpatient
stay if the patient presents any one of the following Multiple monitoring of Disease, treatment with cancer
conditions listed in „column A‟ in combination with vital signs, including chemotherapy or other
anyone of the conditions listed in „column B‟. through the monitor, potentially life-threatening
at least every 4 hours. substances

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Daycare Procedures

Requirements for Coverage Adjudication Examples

ICD9 CM CPT etc. codes to be reported to its
maximum specificity. ICD-9 CM codes to be Example 1
medically necessary for the respective procedure. Question: A 35 year old male patient, holding UAE
plan was diagnosed with Ureteral stone as principle
diagnosis (ICD 9 code 592.1) and hydronephrosis
Non-Coverage
as other diagnosis (ICD 9 code 591). The procedure
If any procedure that is available within the day requested is „Cystourethroscopy, with insertion of
care procedures list is performed on inpatient basis, indwelling ureteral stent‟ (CPT 52332). The patient
the coverage will depend on the medical developed post dural puncture head ache.
justification.
Answer: The procedure of „Cystourethroscopy,
Also, Medical justification is required to perform an with insertion of indwelling ureteral stent‟ to be
outpatient procedure (procedure that can be done approved as a daycare. There is no medical
in the outpatient or emergency room like injection, justification for inpatient stay.
Incision and drainage of abscess, suturing etc) on
day care basis.
Example 2
For Visitors plan, any elective procedure or
procedure for a/c exacerbation of chronic or pre- Question: A 55 year old female, holding Regional
existing condition is not covered. plan was diagnosed with senile Cataract unspecified
as principle diagnosis (ICD 9 code 366.10) and
uncontrolled Type 2 Diabetes Mellitus (ICD9 code
Payment and Coding Rules 250.02). The provider claimed one day
Please apply HAAD payment rules and regulations hospitalization for the procedure „Extracapsular
and relevant coding manuals for ICD, CPT, etc. cataract removal with insertion of intraocular lens
prosthesis‟ (CPT 66983).
Day care procedure CPT codes are categorized into
two: Answer: The claims to pay the procedure of
„Extracapsular cataract removal with insertion
1. Ambulatory only procedures
of intraocular lens prosthesis‟ as inpatient as it
These procedures can be performed as ambulatory is medially justified.
or outpatient. These can either be incidental or
simple procedures. Medical necessity is to be
established whenever performed as inpatient.
Denial codes
2. Ambulatory / Inpatient procedures
These procedures can be performed as Code Code description
ambulatory or Inpatient. Service is not clinically indicated based on
MNEC-004 good clinical practice, without additional
The criteria for performing these procedures as
supporting diagnoses/activities
inpatient are as follows:
Payment is included in the allowance for
 More than minimal physiological trespass. PRCE-002
another service
 Associated with excessive blood loss or fluid
shifts.
 High risk of serious post-operative Appendices
complications (e.g.: bleeding or airway
obstruction).
A. Reference
 Duration of procedure more than 2 hours.
1. Bailey & love‟s short Practice of Surgery, 23 rd
 Post-operative pain not controllable with oral
Edition
analgesics after discharge.
2. British Association of Day Surgery
 The patient will not be ambulant at the time
of discharge. 3. British Association of Day Surgery. Spinal
anesthesia in day surgery: A practical guide,
If medically necessary, Daman covers extension of
2004
stay for a procedure performed as day surgery.
Medical necessity is to be established by additional 4. British Association of Day Surgery. Day
ICD-9CM diagnosis. surgery unit index, 2008

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Daycare Procedures

B. Revision History

Date Change(s)

01-07-13 V 2.0: New template

1. V 3.0
2. Disclaimer updated as per system
15-07-14
requirements
3. Restored original effective date

National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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