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Referrals for Specialty Consultation

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

Listed below are examples of services that are referred for specialty consultation. This list provides guidelines and is not intended to be all-inclusive.

  • 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 ten 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
  • 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 CHF management
  • 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.)
  • 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
  • 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)
  • Radioiodine therapy
  • 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
  • Gallbladder disease, if significantly symptomatic
  • Recurrent cysts, lumps or suspicious mammograms
  • 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
  • Ectopic pregnancy
  • Uncertain clinical diagnosis
  • Higher risk members (for example, over-age)
  • Menometrorrhagia
  • 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
  • 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
  • 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 three
  • 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
  • Diagnose, treat, and recommend medication regimen in difficult/complex cases, for example:
    • Depressions that do 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 Clozaril or risperidone is being considered
    • Bipolar disorder where lithium, carbamazepine or thorazine may be needed
  • 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
  • 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
  • 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
  • Brief psychotherapy, including post-traumatic stress disorder (PTSD), grief, recent losses
  • Scrotal mass, testicular, or does not transilluminate
  • 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
  • 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
  • Human immunodeficiency virus (HIV)
  • AIDS
Last Updated: 08/06/2021