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December sixteen rheumatoid arthritis cannabis purchase 75mg indomethacin amex, 2020 Page 15 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4 arthritis zoloft cheap indomethacin 75mg online. Contact Lens Bandage Idaho Medicaid covers the becoming of contact lens for treatment of ocular floor illness for youngsters and adults childhood arthritis definition cheap indomethacin 50 mg without prescription. December sixteen rheumatoid arthritis diet dr oz order indomethacin 50mg, 2020 Page sixteen of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4. Prior authorization requests should include the contact lens prior approval form and doctor documentation to assist the diagnosis of Keratoconus. When requesting custom lenses, note on the request form "custom made contacts for keratoconus, diagnosis H18. You could attain Classic Optical at 1-888-522-2020 and a customer support consultant will assist you, or by faxing a request to 1 (888) 522-2022. Fitting kits for Rose K, Jupiter, Custom Stable, McGuire or Dyna Intra Limbal gasoline permeable lenses are available. After the trial match, please clear and disinfect the lenses earlier than returning the equipment. There is a warranty interval on custom lenses, throughout which era you might exchange the contacts. Participants over the age of 21 are solely eligible for eyeglasses once every four years, when essential to prevent additional degradation of vision. Replacement of broken, lost, or lacking glasses is the accountability of the participant. December sixteen, 2020 Page 18 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services c) Idaho State Plan Alternative Benefit Plan. December sixteen, 2020 Page 19 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4. At a minimum these frames should be thought of: � Cutie metallic (32-15-one hundred fifteen, 32-15-120); � L8005 (36-17-one hundred forty, 38-17-one hundred forty, forty-18-one hundred forty); and � Mainstreet 415 plastic with cable temple (33-20-one hundred fifteen, 36-20-120, 39-20-a hundred twenty five). Participants over the age of 21 essential to prevent additional necessary; please refer to the submit a request. December sixteen, 2020 Page 21 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services "Reimbursement � General. December sixteen, 2020 Page 22 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4. December sixteen, 2020 Page 23 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4. Both spherical and cylindrical prescription may be added together for a similar eye if both numbers are a minus (-). December sixteen, 2020 Page 24 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4. Both the spherical and cylindrical prescription may be added together for a similar eye if both numbers are a plus (+) or a minus (-). December sixteen, 2020 Page 25 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4. December sixteen, 2020 Page 26 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4. December sixteen, 2020 Page 27 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4. Other situations may be aniridea, aphakia, migraine headaches, retinitis pigmentosa, extreme blepharospasm, corneal harm, or congenital abnormalities. Tint may be utilized to a stable lens or as a gradient to the lens and primarily based upon a share. Requests for a special therapeutic rose-coloured tint F41 may be submitted under V2799. December sixteen, 2020 Page 28 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 4. December sixteen, 2020 Page 29 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services Eye Glasses for Cataract Surgery One pair of eyeglasses is covered for all ages following a latest cataract surgery.

Idaho Frame Brochure Page seventy one of 149 Idaho Medicaid Provider Handbook Eye and Vision Services a) V2020 Child Frame List V2020 Child Frame List Frame Name 7710 7712 14th Avenue fifth Avenue Active Adam Adorable Amber Anne Answer Aries Attitude 18 Banzai Bashful Beth Bicycle Brave Buzz Candia Capricorn Care Caribbean Catchy Certain Cheerful Chelsea Chill Chris Climb Clout Clutch Compliment Concert Confetti Connie Cosmo Cutie Cyclone Dawn Dazzle Degree Effective 01/20/2020 Manufacturer Capri Optics Capri Optics Limited Editions Limited Editions Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Zimco Optics Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Limited Editions Modern Optical Modern Optical Zimco Optics Modern Optical Modern Optical Modern Optical Zimco Optics Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Modern Optical Material Metal Metal Plastic Plastic Plastic Plastic Plastic Plastic Plastic Plastic Metal Plastic Metal Plastic Metal Plastic Plastic Plastic Plastic Metal Plastic Metal Plastic Plastic Metal Metal Plastic Plastic Plastic Plastic Plastic Plastic Plastic Plastic Plastic Plastic Metal Metal arthritis pain every day discount indomethacin 50 mg without a prescription, Rimless Metal Metal Plastic Page seventy two of 149 National Vision Administrators arthritis pain arm shoulder indomethacin 50 mg discount, L arthritis in neck solutions buy generic indomethacin 50 mg on line. Idaho Frame Brochure Idaho Medicaid Provider Handbook V2020 Child Frame List Frame Name L6016 L6017 L6018 L7001 L7002 L7003 L7004 L7005 L7006 L7007 L7008 L7010 L7011 L7012 L7015 L7016 L7017 L8001 L8002 L8003 L8004 L8005 L8006 L8007 L8008 L8009 L8010 L8011 L8012 L8013 L8014 L8015 L8016 L8017 L8018 L8019 L8020 L8021 L8022 L8023 L8024 L8026 L8027 L8028 L8029 L8030 Launch Effective 01/20/2020 Manufacturer Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Lantis Modern Optical Eye and Vision Services Material Plastic Plastic Plastic Metal Plastic Metal Metal Metal Plastic Plastic Plastic Metal Metal Metal Plastic Plastic Plastic Metal Plastic Metal Metal Metal Plastic Plastic Metal Metal Metal Metal Metal Plastic Plastic Plastic Plastic Plastic Plastic Plastic Plastic Metal Metal Metal Metal Plastic Plastic Plastic Plastic Plastic Plastic Page seventy four of 149 National Vision Administrators arthritis in fingers images discount indomethacin 75 mg visa, L. Idaho Frame Brochure Page ninety five of 149 Idaho Medicaid Provider Handbook Eye and Vision Services g) V2020 Frame Descriptions V2020 Frame Descriptions Material Picture Sizes Colors Burgundy Coffee Ink Frame Name 7710 Manufacturer Capri Optics Metal Spring Hinge, Adjustable Nose Pads 50-18-one hundred forty 7712 Capri Optics Metal Spring Hinge, Adjustable Nose Pads 47-20-one hundred forty Black Coffee Gunmetal 7719 Capri Optics Metal Spring Hinge, Adjustable Nose Pads 54-19-145 fifty six-19-145 60-19-one hundred fifty Black Coffee Gunmetal Black Burgundy Grey Tortoise 14th Limited Editions Avenue Plastic Saddle Bridge 48-16-135 fifth Limited Editions Avenue Plastic Saddle Bridge Mocha Marble Tortoise 47-17-one hundred forty Black Blush Black Burgundy Tortoise Active Modern Optical Plastic Saddle Bridge 51-16-one hundred forty Adam Modern Optical Plastic Saddle Bridge 51-16-one hundred forty fifty three-16-145 Black Brown Grey Adorabl Modern Optical e Plastic Saddle Bridge Black/Blue 47-15-135 Black/Brown Black/Plum Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page ninety six of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Agree Manufacturer Modern Optical Material Plastic Saddle Bridge Picture Eye and Vision Services Sizes Colors Black/Silver Brown/Gold 52-16-one hundred forty Burgundy/Silv er Black/Crystal 51-16-one hundred forty Purple/Lilac Teal/Crystal Amber Modern Optical Plastic Saddle Bridge Anne Modern Optical Plastic Saddle Bridge Black/Burgund y 48-17-135 Brown 50-17-one hundred forty Drk. Blue Black Blue Brown Answer Modern Optical Plastic Saddle Bridge 52-15-one hundred forty Appeal Modern Optical Plastic Saddle Bridge Blue/Purple Grey/Blue 51-20-one hundred forty Tortoise/Burg undy 48-20-one hundred forty 50-20-145 Brown Gold Gunmetal Black Blue Cranberry Aries Modern Optical Metal Spring Hinge, Adjustable Nose Pads Attitude 18 Zimco Optics Plastic Saddle Bridge forty nine-17-135 Banzai Modern Optical Metal Spring Hinge, Adjustable Nose Pads 47-19-135 Blue Brown Matte Black Bashful Modern Optical Plastic Saddle Bridge Black/Crystal Blue/Rose forty two-16-one hundred thirty Burgundy/Blu e Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 97 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Beth Manufacturer Modern Optical Material Metal Spring Hinge, Adjustable Nose Pads Picture Eye and Vision Services Sizes Colors Antique Silver 50-18-135 Gold 52-18-one hundred forty Matte Brown Rose Black Matte Navy Matte Purple Matte Bicycle Modern Optical Plastic Saddle Bridge 45-15-one hundred thirty 47-15-135 Brave Modern Optical Plastic Saddle Hinge, Saddle Bridge 50-15-135 52-15-one hundred forty Black Blue Brown Brown Lilac Rose Bria Modern Optical Metal Spring Hinge, Adjustable Nose Pads fifty three-16-135 Buzz Modern Optical Plastic Saddle Bridge 54-16-145 Black Tortoise Camille Modern Optical Metal Spring Hinge, Adjustable Nose Pads, Nylon Rimless Gunmetal 51-19-135 Light Brown Rose Candia Limited Editions Plastic Saddle Bridge 50-17-one hundred thirty 52-17-135 Black Brown Plum Capricor Modern Optical n Metal Spring Hinge, Adjustable Nose Pads, Nylon Rimless Plastic Saddle Bridge Matte Black 47-20-135 Matte Brown forty nine-20-one hundred forty Matte Silver Black/Crystal forty two-15-a hundred twenty five Navy/Crystal 44-15-one hundred thirty Pink/Crystal 46-15-135 Purple/Crystal Care Modern Optical Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 98 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Caribbe an Manufacturer Material Picture Eye and Vision Services Sizes Colors Brown Gold Gunmetal Zimco Optics Metal Spring Hinge 51-19-one hundred forty Catchy Modern Optical Plastic Saddle Bridge 50-17-one hundred forty 52-17-145 Black Brown Burgundy Black/Lime Brown Burgundy Brown Amber Black Gold Pink Gold Gunmetal Matte Brown Certain Modern Optical Plastic Spring Hinge, Saddle Bridge 48-18-one hundred thirty 50-18-135 Cheerful Modern Optical Metal Spring Hinge, Adjustable Nose Pads forty-18-120 forty two-18-a hundred twenty five 44-18-one hundred thirty Chelsea Zimco Optics Metal Spring Hinge, Adjustable Nose Pads 48-18-135 Chill Modern Optical Plastic Saddle Bridge Black/Blue Black/Lilac Black/Lime Black/Orange 51-17-one hundred forty Black/Pink Black/Purple Black/Red Black/White Black/Turquoi se Blonde 50-20-one hundred forty Demi Amber 52-20-145 Grey Chris Modern Optical Plastic Keyhole Bridge Climb Modern Optical Plastic Saddle Bridge 45-16-one hundred thirty Black/Aqua Matte Black/Lime Matte Black/Red Matte Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page ninety nine of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Clout Manufacturer Modern Optical Material Plastic Saddle Bridge Picture Eye and Vision Services Sizes fifty three-16-145 Colors Black Brown Grey Clutch Modern Optical Plastic Saddle Bridge 52-18-one hundred forty Brown Fade Grey Fade Compli ment Modern Optical Plastic Saddle Bridge Navy Blue Fade fifty three-16-135 Purple Fade Wine Fade Black/Red Black/White fifty three-18-135 Brown/Caram el Blue Fuchsia Teal Concert Modern Optical Plastic Saddle Bridge Confetti Modern Optical Plastic Saddle Bridge 45-16-a hundred twenty five Connie Modern Optical Plastic Saddle Bridge 50-17-135 52-17-one hundred forty 48-20-145 50-20-one hundred fifty 50-22-one hundred fifty 52-22-one hundred fifty 52-24-one hundred fifty 54-22-one hundred fifty 54-24-one hundred fifty 32-15-115 35-15-120 Spring Hinge, Adjustable Nose Pads Brown Grey Rose Cosmo Modern Optical Plastic Saddle Bridge Black Brown Grey Cutie Modern Optical Metal Purple Brown Gold Brown Gunmetal Navy Cyclone Modern Optical Metal Spring Hinge, Adjustable Nose Pads, Nylon Rimless 50-19-one hundred forty Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page a hundred of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Dance Manufacturer Modern Optical Material Metal Saddle Bridge Dawn Modern Optical Metal Spring Hinge, Adjustable Nose Pads Dazzle Modern Optical Metal Spring Hinge, Adjustable Nose Pads Picture Eye and Vision Services Sizes fifty three-16-one hundred forty Colors Black/Aqua Black/Lilac Tortoise Brown Pink Purple Brown Gold Rose 41-16-120 forty three-16-a hundred twenty five 45-16-one hundred thirty forty nine-20-135 51-20-one hundred forty fifty three-20-145 Degree Modern Optical Plastic Saddle Bridge 51-17-135 Black Tortoise Diana Modern Optical Metal Spring Hinge, Adjustable Nose Pads 52-18-135 Brown Lilac Rose Dillon Modern Optical Plastic Saddle Bridge, Spring Hinge 50-19-one hundred forty 52-19-145 54-19-one hundred fifty Black Brown Grey Doug Modern Optical Metal Spring Hinge, Adjustable Nose Pads 52-20-one hundred forty Antique Silver Gold 54-20-145 fifty six-20-145 Matte Brown Downto Limited Editions wn Plastic Saddle Bridge 48-18-one hundred forty Black Burgundy Midnight Tortoise Brown Black Silver Dynamit Modern Optical e Metal Spring Hinge, Adjustable Nose Pads forty two-18-one hundred thirty 45-18-135 47-18-one hundred forty Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 102 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Falcon Manufacturer Modern Optical Material Plastic Saddle Bridge Feline Modern Optical Plastic Saddle Bridge Picture Eye and Vision Services Sizes Colors Black Brown 47-20-one hundred forty Crystal Demi Amber Black Brown Teal Brown Silver Gold 51-19-one hundred forty Finale Modern Optical Metal Spring Hinge, Adjustable Nose Pads 48-19-135 50-19-one hundred forty 52-19-145 Finesse Modern Optical Metal Spring Hinge, Adjustable Nose Pads Brown forty nine-17-135 Matte Black Rose Floral Modern Optical Plastic Saddle Bridge Brown/Black 51-17-one hundred forty Burgundy/Blac k Purple/Black Forbidde Modern Optical n Plastic Saddle Bridge 48-18-one hundred forty Black Tortoise Wine Freedo m Modern Optical Plastic Saddle Bridge Black/Blue 50-16-one hundred forty Black/Burgund y Black/Frost Fregossi 368 Continental Optical Plastic Saddle Bridge 50-18-135 Black Aqua Sunset Gemini Modern Optical Plastic Spring Hinge, Adjustable Nose Pads 47-18-135 Blue Brown Matte Black Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 103 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Genius Manufacturer Material Picture Eye and Vision Services Sizes Colors Tortoise Burgundy Black Modern Optical Plastic Keyhole Bridge 47-21-one hundred forty Gift Modern Optical Plastic Spring Hinge, Saddle Bridge Black/Crystal 47-17-135 Brown/Crystal forty nine-17-one hundred forty Purple/Brown Matte Black fifty three-18-one hundred forty Matte Brown 55-18-145 Matte Gunmetal 54-20-one hundred forty fifty six-20-145 Brown Rose Violet Glenn Modern Optical Metal Spring Hinge, Adjustable Nose Pads Gloria Modern Optical Metal Spring Hinge, Adjustable Nose Pads Goodies Modern Optical Plastic Saddle Bridge Black/Blue 45-16-one hundred thirty Black/Fuchsia Black/Lime Black/White Brown 51-16-one hundred forty Burgundy/Blac k Blue/Purple Grey/Blue 50-19-one hundred forty Tortoise/Burg undy Black Brown Gunmetal Hannah Modern Optical Plastic Saddle Bridge Harper Modern Optical Plastic Saddle Bridge Heat Modern Optical Metal Spring Hinge, Adjustable Nose Pads, Nylon Rimless 50-20-one hundred forty Hector Modern Optical Plastic Saddle Bridge 51-18-one hundred forty Black Brown Hide & Seek Modern Optical Metal Spring Hinge, Adjustable Nose Pads forty two-19-a hundred twenty five 44-19-143 National Vision Administrators, L. Idaho Frame Brochure Brown Navy Purple Effective 01/20/2020 Page 104 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Holiday Manufacturer Material Picture Eye and Vision Services Sizes Colors Black Purple Red Modern Optical Plastic Saddle Bridge 54-17-one hundred forty Hudson Zimco Optics Metal Spring Hinge, Adjustable Nose Pads 47-20-one hundred forty Gold Brown Gunmetal Icon Modern Optical Metal Spring Hinge, Adjustable Nose Pads Antique Silver 51-19-135 Black fifty three-19-one hundred forty Matte Brown Satin Gold Black Matte Blue Matte 47-18-135 Tortoise Matte Incognit Modern Optical o Plastic Saddle Bridge J 4154 (Formerl Hart Specialties y Blvd 4154) Metal Spring Hinge, Adjustable Nose Pads 47-18-135 50-18-one hundred forty Brown Gold Silver James Modern Optical Metal Spring Hinge, Adjustable Nose Pads fifty six-17-one hundred forty fifty eight-17-145 60-17-one hundred fifty 52-18-one hundred forty 54-18-145 fifty six-18-one hundred fifty fifty eight-18-one hundred fifty five 60-18-one hundred fifty five Coffee Gold Gunmetal Jazz Modern Optical Metal Spring Hinge, Adjustable Nose Pads, Plastic Temples Black Brown Gunmetal Joseph Modern Optical Metal Spring Hinge, Adjustable Nose Pads 54-19-one hundred forty Black fifty six-19-145 Matte Brown Silver fifty eight-19-one hundred fifty Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page a hundred and five of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Judi Manufacturer Modern Optical Material Plastic Saddle Bridge Karma Modern Optical Plastic Spring Hinge, Saddle Bridge Picture Eye and Vision Services Sizes 50-16-135 fifty three-16-one hundred forty Colors Black/Crystal Tortoise Wine/Grey Black Brown Lavender 55-16-one hundred forty Keith Modern Optical Metal Spring Hinge, Adjustable Nose Pads 54-16-one hundred forty Antique Silver Gold fifty six-16-145 fifty eight-16-one hundred fifty Matte Brown Matte Black 51-17-135 Matte Brown Matte Plum Black Brown Gunmetal Keynote Zimco Optics Metal Spring Hinge, Adjustable Nose Pads Kody Modern Optical Metal Spring Hinge, Adjustable Nose Pads 52-18-one hundred forty 54-18-145 L6001 Lantis Plastic Wine Crystal 52-16-one hundred thirty Black/Crystal 54-16-135 Purple/Crystal Saddle Bridge Blk/Honey Crystal 52-14-one hundred thirty Brown Crystal Dark Plum Crystal Saddle Bridge L6002 Lantis Plastic L6003 Lantis Plastic Purple/Crystal 52-16-one hundred thirty Black/Crystal 54-16-135 Brown/Crystal Saddle Bridge Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 106 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name L6004 Manufacturer Material Picture Eye and Vision Services Sizes Colors Lantis Plastic Saddle Bridge Black/Magenta 50-16-138 Black/Honey 52-16-135 Wine Crystal L6005 Lantis Metal Spring Hinge, Adjustable Nose Pads Shiny Wine 51-19-one hundred thirty Satin Brown Shiny Black L6006 Lantis Metal 52-18-135 Satin Brown Satin Plum Shiny Wine Spring Hinge, Adjustable Nose Pads L6007 Lantis Metal Spring Hinge, Adjustable Nose Pads Shiny Wine fifty three-18-138 Satin Gold Satin Brown L6008 Lantis Plastic Saddle Bridge Pink/Crystal 51-17-one hundred thirty Brown/Crystal Rose/Crystal L6009 Lantis Metal Satin Brown Shiny Wine 48-18-a hundred twenty five Satin Gold/Brown Spring Hinge, Adjustable Nose Pads Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 107 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name L6010 Manufacturer Material Picture Eye and Vision Services Sizes Colors Satin Brown Satin Black Satin Silver Lantis Metal Spring Hinge, Adjustable Nose Pads forty nine-16-one hundred thirty L6011 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Pink 50-18-one hundred thirty Satin Brown Satin Plum L6012 Lantis Metal Satin Plum forty nine-18-one hundred thirty Satin Brown Shiny Wine Spring Hinge, Adjustable Nose Pads L6016 Lantis Plastic Saddle Bridge fifty three-17-135 Lavender Black Tortoise L6017 Lantis Plastic 52-16-135 Black Brown Purple Saddle Bridge L6018 Lantis Plastic Saddle Bridge 52-17-145 Burgundy Black Lavender L7001 Lantis Metal Spring Hinge, Adjustable Nose Pads Matte Black Satin Brown 54-18-138 Satin Gold/Brown Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 108 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Manufacturer Material Picture Eye and Vision Services Sizes Colors L7002 Lantis Plastic Shiny Black fifty three-16-138 Charcoal/Crys 55-16-one hundred forty tal Brown/Crystal Saddle Bridge Satin Brown Matte Black 52-19-one hundred forty Satin Gunmetal Spring Hinge, Adjustable Nose Pads Satin Gunmetal 52-18-135 Satin Brown Matte Black Spring Hinge, Adjustable Nose Pads Satin Gunmetal 50-19-135 Satin Gold Satin Brown Spring Hinge, Adjustable Nose Pads L7003 Lantis Metal L7004 Lantis Metal L7005 Lantis Metal L7006 Lantis Plastic Saddle Bridge Black/Crystal 55-17-one hundred forty Brown Crystal fifty seven-17-145 Tortoise L7007 Lantis Plastic Shiny Black fifty three-15-145 Brown Crystal 55-17-145 Tortoise Saddle Bridge Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 109 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Manufacturer Material Picture Eye and Vision Services Sizes Colors L7008 Lantis Plastic Brown Crystal fifty three-17-135 Black/Crystal Tortoise Saddle Bridge Satin Brown Dark fifty eight-19-one hundred fifty Gunmetal Satin Gold Spring Hinge, Adjustable Nose Pads Matte Black Satin 54-20-one hundred forty Gunmetal Satin Gold Spring Hinge, Adjustable Nose Pads Satin Dark Brown 54-18-145 Satin Gunmetal Matte Black L7009 Lantis Metal L7010 Lantis Metal L7011 Lantis Metal Spring Hinge, Adjustable Nose Pads L7012 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Gunmetal 51-18-135 Satin Brown Matte Black L7015 Lantis Plastic "Cold Insert" Saddle Bridge 52-18-one hundred forty Black Gray Navy Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 110 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name L7016 Manufacturer Material Picture Eye and Vision Services Sizes Colors Gray Black Tortoise Lantis Plastic Saddle Bridge 55-15-one hundred forty L7017 Lantis Plastic Saddle Bridge Gray 52-17-145 Matte Black Tortoise L8001 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Brown Satin 44-18-a hundred twenty five Gunmetal Satin Navy L8002 Lantis Plastic Saddle Bridge Black/Crystal Brown/Crystal 46-15-a hundred twenty five Purple/Pink Crystal L8003 Lantis Metal Spring Hinge, Adjustable Nose Pads Matte Black/Navy 48-17-135 Satin Brown Satin Gun/Black L8004 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Pink Satin Brown 47-17-one hundred thirty Satin Gun/Black L8005 Lantis Metal Spring Hinge, Adjustable Nose Pads 36-17-one hundred forty 38-17-one hundred forty forty-18-one hundred forty Satin Light Brown Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 111 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name L8006 Manufacturer Material Picture Eye and Vision Services Sizes Colors Lantis Plastic Saddle Bridge Navy/Crystal 45-15-128 Brown/Crystal Black/Crystal L8007 Lantis Plastic Saddle Bridge Black/Crystal 47-16-one hundred thirty Brown/Crystal forty nine-16-one hundred thirty Red/Crystal L8008 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Gunmetal 44-19-one hundred thirty Satin Slate Blue Satin Brown L8009 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Light Plum 46-18-one hundred thirty Satin Gun/Black Satin Brown L8010 Lantis Metal Spring Hinge, Adjustable Nose Pads 45-19-a hundred twenty five Satin Pink Satin Red Satin Brown L8011 Lantis Metal Spring Hinge, Adjustable Nose Pads Slate Blue Satin Brown forty two-18-120 Satin Light Plum L8012 Lantis Metal Spring Hinge, Adjustable Nose Pads 46-18-a hundred twenty five Satin Brown Satin Pink Slate Blue Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 112 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name L8013 Manufacturer Material Picture Eye and Vision Services Sizes Colors Lantis Plastic Saddle Bridge Brown/Crystal 47-16-one hundred thirty Black/Crystal Blue/Crystal L8014 Lantis Plastic Saddle Bridge Blk/Magenta Crystal 48-16-one hundred thirty Purple/Pink 50-16-one hundred thirty Crystal Blk/Green Crystal L8015 Lantis Plastic Saddle Bridge Teal/Crystal 45-17-126 Purple/Crystal Pink/Crystal L8016 Lantis Plastic Saddle Bridge Black/Green Crystal 45-16-127 Brown/Crystal Red/Crystal L8017 Lantis Plastic Saddle Bridge Purple Crystal Black 46-17-one hundred thirty Magenta Crystal L8018 Lantis Plastic Saddle Bridge Teal Blue forty two-16-128 Crystal 45-16-one hundred thirty Pink Crystal Black L8019 Lantis Plastic Saddle Bridge Purple Crystal 45-thirteen-128 Navy Crystal Brown Crystal Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 113 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name L8020 Manufacturer Material Picture Eye and Vision Services Sizes Colors Lantis Plastic Saddle Bridge Black 46-16-135 Brown Crystal 48-14-128 Navy Crystal L8021 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Gun/Navy 50-17-one hundred thirty Matte Black Satin Brown L8022 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Navy Satin 47-15-one hundred thirty Gun/Black Satin Brown L8023 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Magenta 48-16-135 Satin Purple Satin Brown L8024 Lantis Metal Spring Hinge, Adjustable Nose Pads Satin Blk/Purple 48-16-one hundred thirty Satin Brown Satin Plum L8026 Lantis Plastic Saddle Bridge 48-15-one hundred thirty Black Navy Tortoise L8027 Lantis Plastic 46-15-one hundred thirty Rose Black Red Saddle Bridge Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 116 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Mingle Manufacturer Modern Optical Material Plastic Saddle Bridge Picture Eye and Vision Services Sizes fifty three-18-135 Colors Black Brown Burgundy Monaco Modern Optical Metal Spring Hinge, Adjustable Nose Pads 48-18-one hundred forty Brown Gold Gunmetal Monica Modern Optical Plastic Saddle Bridge 50-17-one hundred thirty 52-17-135 54-17-one hundred forty Brown Grey Rose Moscow Zimco Optics Metal Spring Hinge, Adjustable Nose Pads 54-16-one hundred forty fifty six-18-145 fifty eight-18-one hundred fifty Gold Gunmetal Amber Nancy Modern Optical Metal Spring Hinge, Adjustable Nose Pads 52-18-135 Antique Brown Gold Silver Blue Brown Burgundy Black Blue Brown Burgundy Violet Black/Rose Blue/Pink Brown Black Brown Gunmetal Neon Modern Optical Plastic Saddle Bridge 45-19-one hundred forty Ninja Modern Optical Metal Spring Hinge, Adjustable Nose Pads 44-18-one hundred thirty 46-18-135 Now Modern Optical Plastic Saddle Bridge fifty three-15-one hundred forty Overloo k Zimco Optics Metal Spring Hinge, Adjustable Nose Pads 50-24-one hundred forty Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 117 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Manufacturer Material Picture Eye and Vision Services Sizes Colors Amethyst Black Brown Grey Purple Brown Matte Gunmetal Shiny Gold Blue Fade Burgundy Fade Grey Fade Overvie Modern Optical w Plastic Saddle Bridge 50-22-145 Pacific Zimco Optics Metal Spring Hinge, Adjustable Nose Pads fifty three-18-135 Parallel Modern Optical Plastic Saddle Bridge fifty three-20-145 Patches Modern Optical Plastic Saddle Bridge Black/Crystal 45-18-one hundred thirty Navy/Crystal Purple/Crystal Patience Modern Optical Plastic Saddle Bridge Blue Matte Plum Matte 54-14-one hundred forty Black/Tortoise Matte Phase Modern Optical Plastic Saddle Bridge 52-17-145 Blue Burgundy Teal Pixie Modern Optical Plastic Saddle Bridge Brown/Crystal 48-16-one hundred thirty Black/Crystal Plum/Crystal 51-16-one hundred forty fifty three-16-145 Black Brown Navy Plasma Modern Optical Plastic Saddle Bridge Pleasure Modern Optical Plastic Saddle Bridge Black 52-18-one hundred forty Teal/Crystal Tortoise Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 120 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name S310 Manufacturer Material Picture Eye and Vision Services Sizes Colors Brown Blue Pink Zimco Optics Plastic Saddle Bridge 52-16-one hundred forty S313 Zimco Optics Plastic Saddle Bridge 52-16-one hundred forty Blue Pink/Grape Violet S323 Zimco Optics Plastic Saddle Bridge forty nine-19-135 Brown Grey S325 Zimco Optics Plastic Saddle Bridge 48-20-one hundred forty Black/Crystal Brown/Crystal Sadie Modern Optical Plastic Spring Hinge, Saddle Bridge, Laser Engraved Floral Design, Multi-faceted Gemstones forty nine-18-135 Black Brown Burgundy Score Modern Optical Plastic Saddle Bridge 44-15-one hundred thirty 46-15-135 Black Tortoise Sheer Modern Optical Plastic Saddle Bridge 51-15-one hundred forty Black/Blue Black/Mint Black/Violet Skippy Modern Optical Plastic Saddle Bridge 44-16-a hundred twenty five 46-16-one hundred thirty Blue Brown Rose Sky Modern Optical Plastic Saddle Bridge 47-17-one hundred thirty forty nine-17-135 Black Brown Burgundy Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 121 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Slick Manufacturer Material Picture Eye and Vision Services Sizes forty nine-17-135 51-17-one hundred forty 54-17-145 fifty seven-17-one hundred fifty 60-17-one hundred fifty Colors Black Tortoise White Red Modern Optical Plastic Spring Hinge, Saddle Bridge Slide Modern Optical Metal Spring Hinge, Adjustable Nose Pads Matte Black Matte Brown 48-20-135 Matte Burgundy forty two-18-a hundred twenty five 45-18-one hundred thirty 47-18-135 46-20-one hundred thirty 48-20-135 50-20-one hundred forty Blonde Brown Blue Wine Grey Black Brown Violet Blue Brown Purple Black Blue Brown Red Black Blue Brown Black/Navy Black/Pink Black/Red Black/Sky Blue Sneaker Modern Optical s Plastic Saddle Bridge Special Modern Optical Metal Spring Hinge, Adjustable Nose Pads Speckle Modern Optical Plastic Spring Hinge, Saddle Bridge 44-17-one hundred thirty 46-17-135 Splash Modern Optical Plastic Saddle Bridge 46-18-one hundred thirty 48-18-135 Sporty Modern Optical Plastic Spring Hinge, Saddle Bridge 44-17-a hundred twenty five 46-17-one hundred thirty Spunky Modern Optical Plastic Saddle Bridge 47-16-one hundred thirty Storm Modern Optical Plastic Saddle Bridge Black Blonde Blue 48-16-one hundred forty Brown Burgundy Demi Amber Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 124 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Manufacturer Material Picture Eye and Vision Services Sizes 52-18-one hundred forty 54-18-145 fifty six-18-one hundred fifty Colors Brown Grey Smoke Tornado Modern Optical Plastic Saddle Bridge U 14 Capri Optics Plastic Saddle Bridge 48-18-one hundred forty Black Brown Grey U 21 Capri Optics Plastic Saddle Bridge 50-18-145 Black Brown Brown Blue Black Crystal Brown Grey Marble U 23 Capri Optics Plastic Saddle Bridge 48-20-one hundred forty U 32 Capri Optics Plastic Saddle Bridge 50-19-one hundred forty Black Brown Grey U 33 Capri Optics Plastic Not really helpful for powers over +3. Idaho Frame Brochure Page 128 of 149 Idaho Medicaid Provider Handbook V2020 Frame Descriptions Frame Name Windy Manufacturer Modern Optical Material Plastic Saddle Bridge Wow Modern Optical Plastic Saddle Bridge Picture Eye and Vision Services Sizes 41-17-120 forty three-17-a hundred twenty five Colors Black Brown Violet Black/Lime forty nine-16-135 Brown 51-16-one hundred forty Burgundy/Gre y Black/Grey Black/Hot Pink Black/Red Yippee Modern Optical Plastic Saddle Bridge forty nine-18-135 Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 129 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services h) V2025 Frame Descriptions V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Name Picture Sizes Colors Baby Lux Miraflex Plastic Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic 38-17 33 colors (see chart at end) Baby Lux 2 Miraflex Plastic Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic forty-18 28 colors (see chart at end) Baby One Miraflex Plastic Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic 37-14 31 colors (see chart at end) Baby One 2 Miraflex Plastic Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic 44-16 23 colors (see chart at end) Baby Plus Miraflex Plastic 39-14 23 colors (see chart at end) Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic Effective 01/20/2020 National Vision Administrators, L. Idaho Frame Brochure Page 133 of 149 Idaho Medicaid Provider Handbook V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Name Picture Eye and Vision Services Sizes Colors Maxi Baby Miraflex Plastic Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic 38-12 18 colors (see chart at end) Maxi Baby 2 Miraflex Plastic Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic forty-15 15 colors (see chart at end) Mayan 1 Miraflex Plastic Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic 39-14 14 colors (see chart at end) Mayan 2 Miraflex Plastic Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic forty two-15 24 colors (see chart at end) Mayan 3 Miraflex Plastic Soft frames manufactured from flexible material with no steel elements or hinges, saddle bridge, contains headband, Hypoallergenic 47-17 14 colors (see chart at end) Effective 01/20/2020 National Vision Administrators, L.

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Non-critical infections occurred extra usually with ocrelizumab than with placebo or lively comparator arthritis back mayo cheap indomethacin 75 mg with visa, but critical infections were less frequent with ocrelizumab arthritis differential diagnosis generic indomethacin 25 mg fast delivery. Malignancies occurred 3 times as usually with ocrelizumab than with placebo or lively comparator arthritis in cats discount indomethacin 75mg visa. Six sufferers taking ocrelizumab developed breast cancer versus none within the management teams rheumatoid arthritis neck pain cheap indomethacin 75mg with amex. Depression events occurred extra incessantly with ocrelizumab than with Rebif in these trials (8% vs 7%). Eight of the deaths were unlikely to be related to ocrelizumab due to low exposure or lack of current exposure. For the remaining 37 deaths, the reported causes were: pneumonia (7), sepsis/septic shock (6), respiratory failure (three), lung cancer (three), sudden demise/ demise (three), myocardial infarction (2), mind edema, breast cancer, carbon monoxide poisoning, disseminated intravascular coagulation, gastric cancer, gastrointestinal carcinoma, gastrointestinal hemorrhage, ischemic cerebral infarction, multi-organ failure, pulmonary embolism, ruptured cerebral aneurysm, toxicity to various agents, and visitors accident. There was no aplastic anemia, pancytopenia, rhabdomyolysis, Stevens Johnson Syndrome, poisonous epidermal necrolysis, liver failure, or renal failure. The significance of those charges is tough to determine as a result of the other indications were illnesses that had an intrinsically larger baseline adverse event fee and frequent concomitant use of other medicine with excessive adverse event charges. Table 17 and Table 18, beneath, present the intense adverse events charges within the ocrelizumab and management teams for the three largest trials within the application. Pancreatitis this evaluation describes each of those problems with concern under italicized headings beneath. The protocol really helpful pretreatment with oral analgesic medicines and an oral antihistamine. Kanapuru comments that the imbalance of breast cancer cases is concerning and recommends longer follow-as much as characterize the association additional. Boehm and Yasuda agree with the consultants that the label for ocrelizumab ought to listing the danger of malignancy as a Warning and that there should be a requirement to study the incidence of cancer if the drug is permitted. Therefore, as a result of Rebif labeling has a warning about melancholy and suicide, Drs. These adverse reactions have potential for extra critical outcomes within the postmarketing period in which sufferers are monitored less incessantly than within the clinical trial setting. A advice concerning approvability can solely be made based on a consideration of profit and threat. Most of the infusion reactions were gentle and occurred during the infusion period, although some additionally occurred within 24 hours of the infusion but after the affected person had left the clinic. In particular there was an imbalance within the managed trials for breast cancer associated with ocrelizumab use (with 6 cases in women exposed to ocrelizumab vs none in comparator). One case of breast cancer in a (Japanese) male occurred in a Rheumatoid Arthritis Trial, an sudden incidence given the background fee of breast cancer in Japanese males. There is uncertainty concerning potential for extra critical outcomes within the postmarketing period in which sufferers are monitored less incessantly than within the clinical trial setting. I suggest the next postmarketing requirements: Long-time period observational postmarketing requirement to characterize safety with emphasis on the danger of malignancies and infections. Dimension Analysis of Condition Current Treatment Options Evidence and Uncertainties Please refer to Dr. Drug exposure is enough, was at or above the proposed doses, and the demographics of clinical trial subjects reflects the meant population to be used. Ocrelizumab is associated with a threat of infections, and uncertainty exists in whether outcomes of infections could be extra critical in an unmonitored outpatient setting. Ocrelizumab is associated with an increased threat of malignancies, particularly breast cancer in males and in females. This may be particularly necessary within the outpatient setting in which sufferers may be seen less incessantly than within the clinical trials. The 37 deaths that occurred throughout therapy or within 1 year of the final dose included 7 pneumonia (6/7 had acquired other immunosuppressants), 6 sepsis/septic shock (four/6 had acquired corticosteroids and methotrexate), three respiratory failure, three lung cancer, three sudden demise/demise, 2 myocardial infarction, and 1 each of mind edema, breast cancer, carbon monoxide poisoning, disseminated intravascular coagulation, gastric cancer, gastrointestinal carcinoma, gastrointestinal hemorrhage, ischemic cerebral infarction, multi-organ failure, pulmonary embolism, ruptured cerebral aneurysm, toxicity to various agents, and visitors accident. Although the mortality fee for ocrelizumab and placebo were comparable within the managed trials, the ocrelizumab teams had an increased number of an infection/sepsis related deaths (5) compared to placebo (zero). The relationship between the danger for pancreatitis and use of ocrelizumab is unknown.

Therapy is covered initially for one (1) hour per week for twelve (12) weeks reactive arthritis in feet generic indomethacin 75mg with visa, however more could also be requested at the conclusion of the twelve (12) weeks with documentation of achieved progress and continued want arthritis glucosamine 25mg indomethacin with amex. Sessions are to rheumatoid arthritis pregnancy order indomethacin 75 mg on line be one-on-one for an hour every arthritis in legs and feet symptoms cheap indomethacin 25 mg online, however half hour classes could also be licensed if the participant is unable to tolerate a full hour of therapy. December sixteen, 2020 Page 53 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services A concurrent at-home reinforcement program is the standard of care and regarded medically needed for therapy to proceed. If the reinforcement program has not began by the second week of therapy, the provider must document the reason within the therapy document. Only the following locations of service are lined for vision therapy: � 11 � Office; � 19 � Off Campus � Outpatient Hospital; and � 22 � On Campus � Outpatient Hospital. At the top of the initial authorization if adequate progress has not been achieved, requests for extra visits will be denied as different interventions, or a referral to an ophthalmologist, could also be more applicable. Vision Therapy: Additional Documentation Providers must keep documentation as required within the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook. Medical Assistance Program - Services to Be Provided - Experimental Services or Procedures Excluded, Idaho Code 56-209d (2005). This determination was made because of the dearth of statistically significant research after a evaluation of the literature. The research provides some preliminary evidence suggesting efficacy of computer-based rhythm and timing in persistent stroke. However, the sample size was insufficient on this research to demonstrate applicability to any inhabitants. Due to the dearth of sample size this research was not acceptable for inclusion in demonstrating visual processing therapy is a medically needed service. The research had additional issues that prevented it from adequately controlling for the placebo impact and too many variables to enable demonstration of causation between the therapy and the advantages. The sample size was insufficient on this research to demonstrate applicability to any inhabitants. It was not included in determining if visual processing therapy is a medically needed service. The sample size was insufficient on this research to demonstrate applicability to the inhabitants, as well as harms and benefits from the therapy. Research have to be peer-reviewed earlier than it can be thought of by Idaho Medicaid for inclusion in evaluation. Additional evidence-based and peer reviewed research is required with adequately sized control and variable teams and lengthy-term evidence of benefits and harms earlier than these therapies can be reconsidered for protection. December sixteen, 2020 Page fifty seven of 149 Idaho Medicaid Provider Handbook Eye and Vision Services eight. References: Visual Processing Therapy a) Idaho Medicaid Publications "Visual Processing Therapy. Gorman, Patrick (2003), Interactive Metronome � Underlying Neurocognitve Correlates of Effectiveness. D (2019), White Paper: Profound Effects of Interactive Metronome and Brain Balance Exercises on a Subset of Children with Attention Deficit Hyperactivity Disorder. December sixteen, 2020 Page 58 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services c) State Regulations "Medical Necessity (Medically Necessary). Medical Assistance Program � Services to be Provided, Idaho Code 56-255(5)(a) (2018). December sixteen, 2020 Page fifty nine of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 9. Documentation Requirements Documentation requirements applicable in specific conditions are listed all through the handbook for provider comfort. General documentation requirements are additionally required and found within the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook. December sixteen, 2020 Page 60 of 149 Idaho Medicaid Provider Handbook Eye and Vision Services 10.

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• https://www.johnshopkinssolutions.com/wp-content/uploads/2017/10/4-Understanding-Mechanical-Ventilation.pdf
• http://ww.katherinefrank.com/gait_analysis_perry.pdf
• http://www.cfsph.iastate.edu/Factsheets/pdfs/mycobacterium_marinum.pdf
• http://www.exodontia.info/files/Austral_Fam_Phys_2012._Maxillofacial_Trauma.pdf
• https://relaped.com/wp-content/uploads/2018/08/Guidelines-for-Acute-Care-of-the-Neonate_2018.pdf