Referrals for Specialty Consultation
Provider Type
- Physicians
- Hospitals
- Participating Physician Groups (PPG)
- Ancillary
Listed below are examples of services that are referred for specialty consultation. This list provides guidelines and is not intended to be all-inclusive.
Allergy
- Chronic rhinitis if the allergic cause is indicated by IgE or nasal eosinophils or if mechanical obstruction, such as adenoids or tonsils, is obvious
- Hives if urticaria becomes chronic (six to 10 weeks or recurrent)
- Consultation if hospitalized, severe respiratory failure or member is steroid-dependent
- Asthma if difficult diagnostic dilemma, not well controlled with routine therapy, hospitalization or if severe respiratory failure has occurred or if the member has become steroid-dependent
- Significant reactions to stinging insects, chronic eczema, chronic sinusitis, and medication allergies
- Systemic allergic reactions, anaphylaxis
Cardiology - Adult
- Candidates for thrombolysis, stress testing, catheterization, angioplasty, or surgery, and life-threatening arrhythmias, or hemodynamic complications requiring invasive monitoring
- Unstable angina
- Hemodynamically complicated murmur
- Constrictive pericarditis
- Complicated hypertension (failure to respond or adverse response to conventional therapy)
- Angina despite maximal pharmacological therapy with maximally tolerated doses of nitrates, beta-blockers, and calcium channel blockers
- Intractable heart failure and arrhythmias
- Pericardial effusion
- Congenital or valvular disease for non-invasive studies and to define appropriate follow-up
- Evaluate and treat recurrent syncope (cardiac)
- Initial consultation for acute and chronic heart failure management
Cardiology - Pediatric
- Evaluate and treat any non-soft, non-systolic cardiac murmur
- Evaluate cyanosis that does not clear with crying
- Evaluate tachypnea
- Evaluate diminished pulses in any extremity
- Consultation for any member with a syndrome known to have cardiac complications (Down's, Marfan's, etc.)
Dermatology
- Acne that has not resolved or improved after three months
- Severe cystic acne
- Suspicious lesion suggesting melanoma
- Basal or squamous cell carcinomas
- Biopsy of suspicious lesions
Endocrinology
- Coma not rapidly reversible by glucose
- Instability in an established management program
- Brittle diabetes
- Diabetic complications, including retinopathy and nephropathy
- Exophthalmos, moderately severe or symptomatic
- Fine-needle aspiration of thyroid nodules
- Suspected disorders of calcium metabolism, adrenal, gonadal, or pituitary dysfunction
- Growth retardation (non-familial)
- Hyperlipidemia (no response to diet and medication, including two different medications, within one year)
- Radioactive iodine therapy
Gastroenterology
- Bowel obstruction diagnosed
- Polyps or other abnormalities
- Chronic bleeding, acute GI hemorrhage
- Undiagnosed hepatocellular disease or biliary obstruction
- Jaundice complicated by fever
- Severe acute and chronic hepatitis
- Ascites when peritoneal fluid is an exudate, chylous or intractable or if fever persists
- Severely symptomatic hemorrhoids refractory to treatment, may be referred for additional nonsurgical treatment
- Complex inflammatory bowel disease
- Chemotherapy for carcinoma
General Surgery
- Gallbladder disease, if significantly symptomatic
- Recurrent cysts, lumps or suspicious mammograms
Neurology/Neurosurgery
- Myofascial pain syndromes if there is no improvement and an uncertain diagnosis after six to eight weeks of conservative treatment or a progressive neurological deficit
- Seizures that are recurrent or refractory to treatment
- Degenerative neurological disorders
- Confirmation of diagnoses and/or intermittent consultation
- Ischemic attack that is associated with a carotid lesion
- CNS malignancies
- Persistent cervical or lumbosacral herniated nucleus pulposa resistant to conservative management
Obstetrics/Gynecology
- Ectopic pregnancy
- Uncertain clinical diagnosis
- Higher risk members (for example, over-age)
- Menometrorrhagia
Ophthalmology
- High index of suspicion for herpes
- Metallic foreign bodies
- Sudden visual change or loss
- Visual change accompanied by pain
- Sudden onset of flashing lights and floaters
- Any eye symptom not responding to treatment
- Unexplained abnormality on fundoscopic exam
- Sudden visual change or loss
- Pediatric members with dysconjugate gaze
- Lens opacification if associated with intolerable visual impairment
Orthopedics
- Fracture
- Locked knee
- Unstable knee
- Foot problems (deep abscess, gangrene, osteomyelitis)
- Any diabetic foot
- Obvious or apparent ligament tear
- Progressive disability of the knee despite conservative treatment and X-ray showing joint narrowing or gross destruction of the articular surface
Otolaryngology
- Tonsillectomy if three documented episodes within four months or six documented episodes within one year
- Tonsillar obstruction or recurrent peritonsillar abscess
- Acute otitis media, member toxic for 48 hours despite treatment
- Persistent middle ear effusion lasting more than three months with continuous treatment, or persistent infection after three courses of different antibiotics
- Persistent hearing loss or delayed speech and articulation in children under the age of 3
- Persistent retraction of tympanic membranes
- Recurrent epistaxis
- Acute and chronic sinusitis after treatment with antibiotics for 20 days or if infection not responsive in 72 hours
- Nasal obstruction after three months of treatment
- Parotid masses
- Acute or persistent hearing loss not attributable to fluid or wax
- Hoarseness that persists for more than three weeks
Psychiatry
- Diagnose, treat, and recommend medication regimen in difficult/complex cases, for example:
- Depressions that does not respond to 60-day trial of selective serotonin re-uptake inhibitor (SSRI) medications or other antidepressants
- Members who report feeling suicidal or homicidal
- Panic disorders
- For example, continued:
- Severe anxiety states
- Clear somatoform disorders
- Schizophrenic disorders where clozapine or risperidone are being considered
- Bipolar disorder where lithium, carbamazepine or chlorpromazine may be needed
Psychologist
- Diagnosis, treatment and consultation regarding management of clearly emotional issues for which the member or PCP feels the need for consultation
- Psychological testing for clarification of diagnosis to establish a treatment plan
Pulmonology
- Respiratory failure
- Percutaneous lung biopsies
- Pleural biopsies
- Supraclavicular node biopsies
- Pleural effusions not due to heart failure or acute pneumonia
- Unresolved pneumonia
- Neonatal lung disease
- Cystic fibrosis
- Lung masses
- Hemoptysis
- Interstitial disease
- Sarcoidosis
- Tuberculosis
- Unusual infections
- Dyspnea of uncertain etiology
- Sleep disorders
- Complicated asthma, advanced COPD, pulmonary vascular disease, including pulmonary hypertension vasculitis and pulmonary embolism
Rheumatology
- Osteoarthritis, if no response to treatment after three months
- Rheumatoid arthritis if manifestations are not controlled on the treatment program or treatment plan to include surgery
- Collagen vascular diseases depending on the extent and severity of manifestations or complications
Social Workers/Other Credentialed Providers
- Brief psychotherapy, including post-traumatic stress disorder (PTSD), grief, recent losses
Urology/Nephrology
- Scrotal mass, testicular, or does not transilluminate
- Undescended tests
- Prostate suspicious for malignancy or obstructive symptoms that may lead to surgical treatment
- Urinary stones that do not pass in a week (4 mm or less)
- Larger or proximal stones for consideration of removal, stenting or lithotripsy
- Male infertility
- Erectile dysfunction not obviously psychogenic
- Acute renal failure
- Obstructive uropathy
- 50 percent reduction in creatinine clearance
- Nephrotic syndrome
- Circumcision with recurrent balanitis or foreskin problems
Vascular Surgery
- Arterial problems, such as gangrene, ischemic ulcers or ischemic rest pain
- Venous insufficiency with stasis ulcers
- Abdominal aortic aneurysms that are symptomatic, enlarging, or greater than 5 cm in diameter
Infectious Disease
- Human immunodeficiency virus (HIV)
- AIDS