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)  Chest X-ray (CXR)  Chronic bronchitis  Benzonatate (Tessalon Perles)  MRI Chest  Chronic obstructive  Budesonide (Pulmicort,  Pathology – lung pulmonary disease Symbicort) specimens (COPD)  Ciclesonide (Alvesco)  Sputum Cultures  Emphysema  Fluticasone propionate (Advair,  Thoracoscopy/  Reactive airways Flovent) Thoracotomy disease  Formoterol (Dulera, Foradil,  Video-Assisted  Reactive airways Symbicort) Thoracotomy (VAT) dysfunction  Ipratropium (Atrovent)  Wedge resection of the  Respiratory  Levalbuterol (Xopenex) lung conditions due to  Metaproterenol (Alupent) fumes and vapors  Mometasone (Asmanex, Dulera)  Montelukast (Singulair)  N-acetylcysteine (Mucomyst  Oxygen  Pirbuterol (Maxair)  Salmeterol (Advair, Serevent)  Terbutaline (Brethine)  Tiotropium (Spiriva)  Zafirlukast (Accolate)  Zileuton (Zyflo) 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  MRI Chest  Pulmonary fibrosis  Methotrexate (Trexall,  Pathology – lung  Sarcoidosis Rheeumatrex, Rasuvo, Otrexup) specimens  N-acetylcysteine (Mucomyst)  Sputum Cultures  Oxygen  Thoracoscopy/ Thoracotomy  Video-Assisted Thoracotomy (VAT)  Wedge resection of the lung

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Presumptively Compensable Expenses

Presumptively Compensable Medications Presumptively Compensable Condition Category Includes (generic name is listed first, followed Procedures by brand name) 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 specimens  Upper GI Series

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

Prostate Cancer  Sildenafil (Viagra)  Prostate Biopsy  Tamsulosin (Flomax)  Radical Prostatectomy  Radiation Seed Implants

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