Welcome to AmeriHealth Caritas Louisiana dental and vision plan, administered by Avēsis. On this page, you’ll find all the clinical criteria associated with this plan.
Accessibility
All rights reserved. Used with express permission. #2020-106752 (exp. 8/22)
Disclosures
Privacy Policy
Sitemap
Cultural Competency
Notice of Nondiscrimination
Terms and Conditions
©2020 Avēsis Incorporated
©2020 Guardian
AmeriHealth Caritas Louisiana Dental Protocols
AmeriHealth Caritas Louisiana Dental Protocols
Click on the items below to view or download helpful documents.
Dental Protocols
AmeriHealth Caritas Louisiana Clinical Protocols
Members
Providers
Benefits Managers
Search for Provider
Search for Provider
Intermediate Level Routine Eye Exam
Intermediate Level Routine Eye Exam
Click on the items below to view or download helpful documents.
Vision Protocols
Comprehensive Routine Eye Exam
Comprehensive Routine Eye Exam
99204 E/M Exam
99204 E/M Exam
99205 E/M Exam
99205 E/M Exam
99213 E/M Exam
99213 E/M Exam
99214 E/M Exam
99214 E/M Exam
99215 E/M Exam
99215 E/M Exam
Strabismus Surgery in Adults
Strabismus Surgery in Adults
Blepharoplasty and Ptosis Repair
Blepharoplasty and Ptosis Repair
Cataract Extraction w/ insertion of IOL
Cataract Extraction w/ insertion of IOL
Corneal Pachymetry
Corneal Pachymetry
Corneal Topography (Computerized)
Corneal Topography (Computerized)
Extended Ophthalmoscopy (92201)
Extended Ophthalmoscopy (92201)
Extended Ophthalmoscopy (92202)
Extended Ophthalmoscopy (92202)
EYLEA® (aflibercept) Intravitreal Injection
EYLEA® (aflibercept) Intravitreal Injection
Fundus Photography
Fundus Photography
Medically Necessary Contact Lenses
Medically Necessary Contact Lenses
Nasolacrimal Duct Probing & Punctum Dilation
Nasolacrimal Duct Probing & Punctum Dilation
Punctal Occlusion by Plugs
Punctal Occlusion by Plugs
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Tear Osmolarity Testing
Tear Osmolarity Testing
Visual Evoked Potential (VEP) Testing
Visual Evoked Potential (VEP) Testing
Vision Therapy
Vision Therapy
Visual Field Testing
Visual Field Testing
YAG (Yttrium-Aluminum Garnet) Laser Surgery
YAG (Yttrium-Aluminum Garnet) Laser Surgery
Programs