Presumptively Compensable Expenses

Presumptively Compensable Expenses If your eligible condition falls within one of the categories in this table, the VCF will presume that any expense for the medications and procedures listed in the table is related to your eligible condition and you do not need to provide any further proof of the relationship when filing an amendment for medical expense reimbursement. You still must complete the Medical Expense Worksheet to list the specific expense. Please note that this list is subject to change. Please be sure to refer to the most recent chart posted to the VCF website prior to filing your amendment for medical expenses.

Presumptively Compensable Medications Presumptively Compensable Condition Category Includes (generic name is listed first, followed Procedures by brand name) Obstructive Airway  Asthma  Albuterol (ProAir, Proventil,  Bronchoscopy Disease  Bronchiectasis Ventolin)  CAT Scan Chest/Thorax  Chronic airway  Atrovent (ipratropium) (CT)(CT Scan) obstruction  Beclomethasone (Qvar)  PET Scan Chest/Thorax  Chronic bronchitis  Benzonatate (Tessalon Perles)  Chest X-ray (CXR)  Chronic obstructive  Budesonide (Pulmicort,  MRI Chest pulmonary disease Symbicort)  Pathology – lung (COPD)  Ciclesonide (Alvesco) specimens  Emphysema  Fluticasone propionate (Advair,  Sputum Cultures  Reactive airways Flovent)  Thoracoscopy/ disease  Formoterol (Dulera, Foradil, Thoracotomy  Reactive airways Symbicort)  Video-Assisted dysfunction  Ipratropium (Atrovent) Thoracotomy (VAT)  Respiratory  Levalbuterol (Xopenex)  Wedge resection of the conditions due to  Metaproterenol (Alupent) lung fumes and vapors  Mometasone (Asmanex, Dulera)  Lung transplantation  Montelukast (Singulair)  N-acetylcysteine (Mucomyst  Oxygen  Pirbuterol (Maxair)  Salmeterol (Advair, Serevent)  Terbutaline (Brethine)  Tiotropium (Spiriva)  Zafirlukast (Accolate)  Zileuton (Zyflo)  Expectorants  All Bronchodilators  Antibiotics  Oral corticosteroids

Updated: December 2020 www.vcf.gov / VCF Helpline 1-855-885-1555

Presumptively Compensable Expenses

Presumptively Compensable Medications Presumptively Compensable Condition Category Includes (generic name is listed first, followed Procedures by brand name) Interstitial Lung  Asbestosis  Azathioprine (AZA, Imuran)  Bronchoscopy Disease  Granulomatosis  Cyclophosphamide (Cytoxan)  CAT Scan Chest/Thorax  Interstitial  Cyclosporine (Restasis, (CT)(CT Scan) pneumonia Sandimmune, Neoral, Gengraf,  Chest X-ray (CXR)  Pneumonitis Apo-Cyclosporine)  PET Scan Chest/Thorax  Pulmonary fibrosis  Methotrexate (Trexall,  MRI Chest  Sarcoidosis Rheeumatrex, Rasuvo, Otrexup)  Pathology – lung  Pneumoconioses  N-acetylcysteine (Mucomyst) specimens  Guaifenesin (Mucinex)  Sputum Cultures  Oxygen  Thoracoscopy/  Oral corticosteroids Thoracotomy  Antibiotics  Video-Assisted  Expectorants Thoracotomy (VAT)  Wedge resection of the lung  Lung transplantation

Gastroesophageal  Esomeprazole (Nexium)  Barium Swallow Reflux  Famotidine (Pepcid)  Esophagogastroduodenosc  Lansoprazole (Prevacid) opy (EGD)  Omeprazole (Prilosec)  Laryngopharyngeal  Pantoprazole (Protonix) Endoscopy  Ranitidine (Zantac)  Pathology – Esophagus, gastric, duodenum  Proton pump inhibitors specimens  Upper GI Series

Upper Respiratory  Rhinitis  Azelastine (Astelin, Astepro)  CAT Scan Head/Sinuses Disease  Sinusitis  Budesonide (Rhinocort)  PET Scan sinuses  Rhinosinusitis  Fluticasone propionate (Flonase)  Endoscopy of Nasal and  Tracheitis  Ipratropium bromide (Atrovent) Sinus Cavities  Laryngotracheitis  Mometasone (Nasonex,  Laryngopharyngeal  Laryngitis Asmanex) Endoscopy  Nasopharyngitis  Oxymetazoline (Afrin)  Pathology – Nasal and Sinus specimens  Pharyngitis  Oral corticosteroids  Antibiotics  Septoplasty  Decongestants  Cultures – Nasal, Mastoid, Sputum

Updated: December 2020 www.vcf.gov / VCF Helpline 1-855-885-1555

Presumptively Compensable Expenses

Presumptively Compensable Medications Presumptively Compensable Condition Category Includes (generic name is listed first, followed Procedures by brand name) Prostate Cancer Erectile Dysfunction:  MRI Prostate  Sildenafil (Viagra)  Prostate Biopsy  Tadalafil (Cialis)  Radical Prostatectomy  Radiation Seed Implants Urinary Incontinence:  External beam radiation  Tamsulosin (Flomax)  Cryotherapy (also known as  Oxybutynin (Ditropan XL) cryoabalation, cryosurgery)  Tolterodine (Detrol)  Orchiectomy (for hormone  Darifenacin (Enablex) suppression)  Fesoterodine (Toviaz)  PSA levels (for active  Solifenacin (Vesicare) surveillance)  Trospium (Sanctura)  Mirabegron (Myrbetriq)

Chemotherapy:  Docetaxel(Taxotere)  Cabazitaxel(Jevtana)  Mitoxantrone(Novantrone)  Estramustine (Emcyt)

Immunotherapy:  Pembrolizumab (Keytruda)  Provenge vaccine

Updated: December 2020 www.vcf.gov / VCF Helpline 1-855-885-1555