Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-ballot - STU 2.2 - Ballot

Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions

## : PAS LOINC Attachment Codes Value Set

Page standards status: Trial-use | Maturity Level: 3

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    <ValueSet xmlns="http://hl7.org/fhir">
      <id value="pas-loinc-attachment-codes"/>
      <language value="en"/>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ValueSet pas-loinc-attachment-codes</b></p><a name="pas-loinc-attachment-codes"> </a><a name="hcpas-loinc-attachment-codes"> </a><ul><li>Include these codes as defined in <a href="http://loinc.org"><code>http://loinc.org</code></a><span title="Version is not explicitly stated. No matching Code System found"> version Not Stated (use latest from terminology server)</span><table class="none"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td></tr><tr><td><a href="https://loinc.org/11526-1/">11526-1</a></td><td>Pathology study</td></tr><tr><td><a href="https://loinc.org/11488-4/">11488-4</a></td><td>Consult note</td></tr><tr><td><a href="https://loinc.org/80792-5/">80792-5</a></td><td>Pulmonary Diagnostic study note</td></tr><tr><td><a href="https://loinc.org/47420-5/">47420-5</a></td><td>Functional status assessment note</td></tr><tr><td><a href="https://loinc.org/34117-2/">34117-2</a></td><td>History and physical note</td></tr><tr><td><a href="https://loinc.org/74156-1/">74156-1</a></td><td>Oncology Plan of care and summary note</td></tr><tr><td><a href="https://loinc.org/18776-5/">18776-5</a></td><td>Plan of care note</td></tr><tr><td><a href="https://loinc.org/80785-9/">80785-9</a></td><td>Radiation oncology Plan of care note</td></tr><tr><td><a href="https://loinc.org/11506-3/">11506-3</a></td><td>Progress note</td></tr><tr><td><a href="https://loinc.org/11504-8/">11504-8</a></td><td>Surgical operation note</td></tr><tr><td><a href="https://loinc.org/18842-5/">18842-5</a></td><td>Discharge summary</td></tr><tr><td><a href="https://loinc.org/34133-9/">34133-9</a></td><td>Summary of episode note</td></tr><tr><td><a href="https://loinc.org/18761-7/">18761-7</a></td><td>Transfer summary note</td></tr><tr><td><a href="https://loinc.org/80565-5/">80565-5</a></td><td>Medication administration record</td></tr><tr><td><a href="https://loinc.org/28570-0/">28570-0</a></td><td>Procedure note</td></tr><tr><td><a href="https://loinc.org/57133-1/">57133-1</a></td><td>Referral note</td></tr><tr><td><a href="https://loinc.org/52027-0/">52027-0</a></td><td>Abortion consent Document</td></tr><tr><td><a href="https://loinc.org/52028-8/">52028-8</a></td><td>Hysterectomy consent Document</td></tr><tr><td><a href="https://loinc.org/52029-6/">52029-6</a></td><td>Sterilization consent Document</td></tr><tr><td><a href="https://loinc.org/53245-7/">53245-7</a></td><td>Driver license</td></tr><tr><td><a href="https://loinc.org/57828-6/">57828-6</a></td><td>Prescription list</td></tr><tr><td><a href="https://loinc.org/18682-5/">18682-5</a></td><td>Ambulance records</td></tr><tr><td><a href="https://loinc.org/52063-5/">52063-5</a></td><td>Prescription for durable medical equipment (DME)</td></tr><tr><td><a href="https://loinc.org/52062-7/">52062-7</a></td><td>Transcutaneous electrical neural stimulation (TENS) attachment</td></tr><tr><td><a href="https://loinc.org/52073-4/">52073-4</a></td><td>Vision services attachment</td></tr><tr><td><a href="https://loinc.org/52070-0/">52070-0</a></td><td>Workers compensation attachment</td></tr><tr><td><a href="https://loinc.org/80405-4/">80405-4</a></td><td>Provider Certification [Type]</td></tr><tr><td><a href="https://loinc.org/53242-4/">53242-4</a></td><td>Charge ticket or encounter form</td></tr><tr><td><a href="https://loinc.org/52042-9/">52042-9</a></td><td>Continuous positive airway pressure (CPAP) attachment</td></tr><tr><td><a href="https://loinc.org/52040-3/">52040-3</a></td><td>Dental X-rays and other images (not DICOM)</td></tr><tr><td><a href="https://loinc.org/18748-4/">18748-4</a></td><td>Diagnostic imaging study</td></tr><tr><td><a href="https://loinc.org/53243-2/">53243-2</a></td><td>Advanced beneficiary notice</td></tr><tr><td><a href="https://loinc.org/53247-3/">53247-3</a></td><td>Eligibility acknowledgement</td></tr><tr><td><a href="https://loinc.org/52071-8/">52071-8</a></td><td>Employee assistance program attachment</td></tr><tr><td><a href="https://loinc.org/67796-3/">67796-3</a></td><td>EMS patient care report - version 3 Document NEMSIS</td></tr><tr><td><a href="https://loinc.org/77601-3/">77601-3</a></td><td>Enhanced note</td></tr><tr><td><a href="https://loinc.org/52043-7/">52043-7</a></td><td>Enteral nutrition attachment</td></tr><tr><td><a href="https://loinc.org/11514-7/">11514-7</a></td><td>Chiropractic Episode of care medical records</td></tr><tr><td><a href="https://loinc.org/11521-2/">11521-2</a></td><td>Occupational therapy Episode of care medical records</td></tr><tr><td><a href="https://loinc.org/11515-4/">11515-4</a></td><td>Physical therapy Episode of care medical records</td></tr><tr><td><a href="https://loinc.org/11516-2/">11516-2</a></td><td>Physician Episode of care medical records</td></tr><tr><td><a href="https://loinc.org/11517-0/">11517-0</a></td><td>Podiatry Episode of care medical records</td></tr><tr><td><a href="https://loinc.org/11518-8/">11518-8</a></td><td>Psychology Episode of care medical records</td></tr><tr><td><a href="https://loinc.org/11519-6/">11519-6</a></td><td>Social service Episode of care medical records</td></tr><tr><td><a href="https://loinc.org/11520-4/">11520-4</a></td><td>Speech therapy Episode of care medical records</td></tr><tr><td><a href="https://loinc.org/52030-4/">52030-4</a></td><td>Explanation of benefits</td></tr><tr><td><a href="https://loinc.org/52031-2/">52031-2</a></td><td>Explanation of benefits to subscriber</td></tr><tr><td><a href="https://loinc.org/52044-5/">52044-5</a></td><td>External infusion pump attachment</td></tr><tr><td><a href="https://loinc.org/103567-4/">103567-4</a></td><td>Path report IG</td></tr><tr><td><a href="https://loinc.org/52064-3/">52064-3</a></td><td>Worker's compensation first report of injury attachment</td></tr><tr><td><a href="https://loinc.org/52045-2/">52045-2</a></td><td>Gait trainers attachment</td></tr><tr><td><a href="https://loinc.org/52033-8/">52033-8</a></td><td>General correspondence attachment</td></tr><tr><td><a href="https://loinc.org/11485-0/">11485-0</a></td><td>Anesthesia records</td></tr><tr><td><a href="https://loinc.org/52035-3/">52035-3</a></td><td>Home health claims</td></tr><tr><td><a href="https://loinc.org/52036-1/">52036-1</a></td><td>Home health prior authorization</td></tr><tr><td><a href="https://loinc.org/52046-0/">52046-0</a></td><td>Hospital beds attachment</td></tr><tr><td><a href="https://loinc.org/52032-0/">52032-0</a></td><td>Appeal denial letter</td></tr><tr><td><a href="https://loinc.org/52047-8/">52047-8</a></td><td>Immunosuppressive drug attachment</td></tr><tr><td><a href="https://loinc.org/77600-5/">77600-5</a></td><td>Interval note</td></tr><tr><td><a href="https://loinc.org/94093-2/">94093-2</a></td><td>Itemized bill</td></tr><tr><td><a href="https://loinc.org/15508-5/">15508-5</a></td><td>Labor and delivery records</td></tr><tr><td><a href="https://loinc.org/11502-2/">11502-2</a></td><td>Laboratory report</td></tr><tr><td><a href="https://loinc.org/52048-6/">52048-6</a></td><td>Lymphedema pump attachment</td></tr><tr><td><a href="https://loinc.org/52049-4/">52049-4</a></td><td>Manual wheelchair attachment</td></tr><tr><td><a href="https://loinc.org/11503-0/">11503-0</a></td><td>Medical records</td></tr><tr><td><a href="https://loinc.org/28011-5/">28011-5</a></td><td>Emergency department Medical records</td></tr><tr><td><a href="https://loinc.org/94118-7/">94118-7</a></td><td>Medical records in response to authorization denial</td></tr><tr><td><a href="https://loinc.org/52037-9/">52037-9</a></td><td>Member ID card copy</td></tr><tr><td><a href="https://loinc.org/52065-0/">52065-0</a></td><td>Automobile liability attachment</td></tr><tr><td><a href="https://loinc.org/52050-2/">52050-2</a></td><td>Motorized wheelchair attachment</td></tr><tr><td><a href="https://loinc.org/76641-0/">76641-0</a></td><td>Neurology study</td></tr><tr><td><a href="https://loinc.org/52072-6/">52072-6</a></td><td>Non-emergency transportation attachment</td></tr><tr><td><a href="https://loinc.org/53246-5/">53246-5</a></td><td>Non-medical services attachment</td></tr><tr><td><a href="https://loinc.org/52066-8/">52066-8</a></td><td>Notice of Discharge Medicare Appeal Rights (NODMAR) form</td></tr><tr><td><a href="https://loinc.org/53244-0/">53244-0</a></td><td>Notice of privacy practices receipt</td></tr><tr><td><a href="https://loinc.org/52051-0/">52051-0</a></td><td>Orthotic/Prosthetic attachment</td></tr><tr><td><a href="https://loinc.org/52052-8/">52052-8</a></td><td>Osteogenesis stimulator attachment</td></tr><tr><td><a href="https://loinc.org/52053-6/">52053-6</a></td><td>Oxygen attachment</td></tr><tr><td><a href="https://loinc.org/52054-4/">52054-4</a></td><td>Parenteral nutrition attachment</td></tr><tr><td><a href="https://loinc.org/52067-6/">52067-6</a></td><td>Past filing limit justification</td></tr><tr><td><a href="https://loinc.org/52034-6/">52034-6</a></td><td>Payer letter</td></tr><tr><td><a href="https://loinc.org/28629-4/">28629-4</a></td><td>Perimetry study</td></tr><tr><td><a href="https://loinc.org/74030-8/">74030-8</a></td><td>Periodontal service attachment</td></tr><tr><td><a href="https://loinc.org/28633-6/">28633-6</a></td><td>Polysomnography (sleep) study</td></tr><tr><td><a href="https://loinc.org/52055-1/">52055-1</a></td><td>Power operated vehicle attachment</td></tr><tr><td><a href="https://loinc.org/57073-9/">57073-9</a></td><td>Prenatal records</td></tr><tr><td><a href="https://loinc.org/52041-1/">52041-1</a></td><td>Blood glucose monitor attachment</td></tr><tr><td><a href="https://loinc.org/52068-4/">52068-4</a></td><td>Property and casualty state mandated forms</td></tr><tr><td><a href="https://loinc.org/52075-9/">52075-9</a></td><td>Purchase invoice</td></tr><tr><td><a href="https://loinc.org/18823-5/">18823-5</a></td><td>Alcohol and/or substance abuse service attachment</td></tr><tr><td><a href="https://loinc.org/18824-3/">18824-3</a></td><td>Cardiac service attachment</td></tr><tr><td><a href="https://loinc.org/18825-0/">18825-0</a></td><td>Medical social services attachment</td></tr><tr><td><a href="https://loinc.org/18826-8/">18826-8</a></td><td>Occupational therapy service attachment</td></tr><tr><td><a href="https://loinc.org/19002-5/">19002-5</a></td><td>Physical therapy service attachment</td></tr><tr><td><a href="https://loinc.org/18594-2/">18594-2</a></td><td>Psychiatric service attachment</td></tr><tr><td><a href="https://loinc.org/52184-9/">52184-9</a></td><td>Pulmonary therapy service attachment</td></tr><tr><td><a href="https://loinc.org/19003-3/">19003-3</a></td><td>Respiratory therapy service attachment</td></tr><tr><td><a href="https://loinc.org/29206-0/">29206-0</a></td><td>Speech therapy service attachment</td></tr><tr><td><a href="https://loinc.org/52056-9/">52056-9</a></td><td>Repair of durable medical equipment attachment</td></tr><tr><td><a href="https://loinc.org/52057-7/">52057-7</a></td><td>Seat lift mechanism attachment</td></tr><tr><td><a href="https://loinc.org/52058-5/">52058-5</a></td><td>Seating system attachment</td></tr><tr><td><a href="https://loinc.org/52039-5/">52039-5</a></td><td>Skilled Nursing Facility (SNF) record</td></tr><tr><td><a href="https://loinc.org/101657-5/">101657-5</a></td><td>Special investigation unit (SIU) medical record request Document</td></tr><tr><td><a href="https://loinc.org/52059-3/">52059-3</a></td><td>Speech generating device attachment</td></tr><tr><td><a href="https://loinc.org/52060-1/">52060-1</a></td><td>Standers/standing frame attachment</td></tr><tr><td><a href="https://loinc.org/52038-7/">52038-7</a></td><td>Subscriber Information including retroactive and presumptive eligibility</td></tr><tr><td><a href="https://loinc.org/52061-9/">52061-9</a></td><td>Support surface attachment</td></tr><tr><td><a href="https://loinc.org/52069-2/">52069-2</a></td><td>Tax ID number - IRS form W9</td></tr><tr><td><a href="https://loinc.org/103595-5/">103595-5</a></td><td>Certificate of Medical Necessity</td></tr><tr><td><a href="https://loinc.org/103596-3/">103596-3</a></td><td>Durable medical equipment proof of delivery receipt</td></tr><tr><td><a href="https://loinc.org/103597-1/">103597-1</a></td><td>Pain management form or template</td></tr><tr><td><a href="https://loinc.org/46212-7/">46212-7</a></td><td>Pre operative photo</td></tr><tr><td><a href="https://loinc.org/52459-5/">52459-5</a></td><td>CMS certification number (CCN) Provider</td></tr></table></li></ul></div>
      </text>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
        <valueCode value="fm"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm">
        <valueInteger value="3">
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
            <valueCanonical
                            value="http://hl7.org/fhir/us/davinci-pas/ImplementationGuide/hl7.fhir.us.davinci-pas"/>
          </extension>
        </valueInteger>
      </extension>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
        <valueCode value="trial-use">
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
            <valueCanonical
                            value="http://hl7.org/fhir/us/davinci-pas/ImplementationGuide/hl7.fhir.us.davinci-pas"/>
          </extension>
        </valueCode>
      </extension>
      <url
           value="http://hl7.org/fhir/us/davinci-pas/ValueSet/pas-loinc-attachment-codes"/>
      <identifier>
        <system value="http://loinc.org"/>
        <value value="valid-hl7-attachment-requests"/>
      </identifier>
      <identifier>
        <system value="urn:ietf:rfc:3986"/>
        <value value="urn:oid:1.3.6.1.4.1.12009.10.2.6"/>
      </identifier>
      <version value="2.2.0-ballot"/>
      <name value="PASLOINCAttachmentCodesValueSet"/>
      <title value="PAS LOINC Attachment Codes Value Set"/>
      <status value="active"/>
      <experimental value="false"/>
      <date value="2022-06-29"/>
      <publisher value="HL7 International / Financial Management"/>
      <contact>
        <name value="HL7 International / Financial Management"/>
        <telecom>
          <system value="url"/>
          <value value="http://hl7.org/Special/committees/fm"/>
        </telecom>
        <telecom>
          <system value="email"/>
          <value value="fmlists@lists.hl7.org"/>
        </telecom>
      </contact>
      <contact>
        <name value="Jean Duteau"/>
        <telecom>
          <system value="email"/>
          <value value="mailto:jean@duteaudesign.com"/>
        </telecom>
      </contact>
      <contact>
        <name value="HL7 International / Financial Management"/>
        <telecom>
          <system value="url"/>
          <value value="http://www.hl7.org/Special/committees/fm"/>
        </telecom>
      </contact>
      <description
                   value="This value set includes LOINC terms that can be sent by a payer as part of an HL7 attachment request for additional information. It has been curated by the HL7 Payer/Provider Information Exchange (PIE) Work Group.  More information about using LOINC in HIPAA attachments and the source of this value set can be found at [LOINC Attahments](https://loinc.org/attachments/)."/>
      <jurisdiction>
        <coding>
          <system value="urn:iso:std:iso:3166"/>
          <code value="US"/>
          <display value="United States of America"/>
        </coding>
      </jurisdiction>
      <copyright
                 value="This material contains content from LOINC (http://loinc.org). LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc."/>
      <compose>
        <include>
          <system value="http://loinc.org"/>
          <concept>
            <code value="11526-1"/>
            <display value="Pathology study"/>
          </concept>
          <concept>
            <code value="11488-4"/>
            <display value="Consult note"/>
          </concept>
          <concept>
            <code value="80792-5"/>
            <display value="Pulmonary Diagnostic study note"/>
          </concept>
          <concept>
            <code value="47420-5"/>
            <display value="Functional status assessment note"/>
          </concept>
          <concept>
            <code value="34117-2"/>
            <display value="History and physical note"/>
          </concept>
          <concept>
            <code value="74156-1"/>
            <display value="Oncology Plan of care and summary note"/>
          </concept>
          <concept>
            <code value="18776-5"/>
            <display value="Plan of care note"/>
          </concept>
          <concept>
            <code value="80785-9"/>
            <display value="Radiation oncology Plan of care note"/>
          </concept>
          <concept>
            <code value="11506-3"/>
            <display value="Progress note"/>
          </concept>
          <concept>
            <code value="11504-8"/>
            <display value="Surgical operation note"/>
          </concept>
          <concept>
            <code value="18842-5"/>
            <display value="Discharge summary"/>
          </concept>
          <concept>
            <code value="34133-9"/>
            <display value="Summary of episode note"/>
          </concept>
          <concept>
            <code value="18761-7"/>
            <display value="Transfer summary note"/>
          </concept>
          <concept>
            <code value="80565-5"/>
            <display value="Medication administration record"/>
          </concept>
          <concept>
            <code value="28570-0"/>
            <display value="Procedure note"/>
          </concept>
          <concept>
            <code value="57133-1"/>
            <display value="Referral note"/>
          </concept>
          <concept>
            <code value="52027-0"/>
            <display value="Abortion consent Document"/>
          </concept>
          <concept>
            <code value="52028-8"/>
            <display value="Hysterectomy consent Document"/>
          </concept>
          <concept>
            <code value="52029-6"/>
            <display value="Sterilization consent Document"/>
          </concept>
          <concept>
            <code value="53245-7"/>
            <display value="Driver license"/>
          </concept>
          <concept>
            <code value="57828-6"/>
            <display value="Prescription list"/>
          </concept>
          <concept>
            <code value="18682-5"/>
            <display value="Ambulance records"/>
          </concept>
          <concept>
            <code value="52063-5"/>
            <display value="Prescription for durable medical equipment (DME)"/>
          </concept>
          <concept>
            <code value="52062-7"/>
            <display
                     value="Transcutaneous electrical neural stimulation (TENS) attachment"/>
          </concept>
          <concept>
            <code value="52073-4"/>
            <display value="Vision services attachment"/>
          </concept>
          <concept>
            <code value="52070-0"/>
            <display value="Workers compensation attachment"/>
          </concept>
          <concept>
            <code value="80405-4"/>
            <display value="Provider Certification [Type]"/>
          </concept>
          <concept>
            <code value="53242-4"/>
            <display value="Charge ticket or encounter form"/>
          </concept>
          <concept>
            <code value="52042-9"/>
            <display
                     value="Continuous positive airway pressure (CPAP) attachment"/>
          </concept>
          <concept>
            <code value="52040-3"/>
            <display value="Dental X-rays and other images (not DICOM)"/>
          </concept>
          <concept>
            <code value="18748-4"/>
            <display value="Diagnostic imaging study"/>
          </concept>
          <concept>
            <code value="53243-2"/>
            <display value="Advanced beneficiary notice"/>
          </concept>
          <concept>
            <code value="53247-3"/>
            <display value="Eligibility acknowledgement"/>
          </concept>
          <concept>
            <code value="52071-8"/>
            <display value="Employee assistance program attachment"/>
          </concept>
          <concept>
            <code value="67796-3"/>
            <display value="EMS patient care report - version 3 Document NEMSIS"/>
          </concept>
          <concept>
            <code value="77601-3"/>
            <display value="Enhanced note"/>
          </concept>
          <concept>
            <code value="52043-7"/>
            <display value="Enteral nutrition attachment"/>
          </concept>
          <concept>
            <code value="11514-7"/>
            <display value="Chiropractic Episode of care medical records"/>
          </concept>
          <concept>
            <code value="11521-2"/>
            <display
                     value="Occupational therapy Episode of care medical records"/>
          </concept>
          <concept>
            <code value="11515-4"/>
            <display value="Physical therapy Episode of care medical records"/>
          </concept>
          <concept>
            <code value="11516-2"/>
            <display value="Physician Episode of care medical records"/>
          </concept>
          <concept>
            <code value="11517-0"/>
            <display value="Podiatry Episode of care medical records"/>
          </concept>
          <concept>
            <code value="11518-8"/>
            <display value="Psychology Episode of care medical records"/>
          </concept>
          <concept>
            <code value="11519-6"/>
            <display value="Social service Episode of care medical records"/>
          </concept>
          <concept>
            <code value="11520-4"/>
            <display value="Speech therapy Episode of care medical records"/>
          </concept>
          <concept>
            <code value="52030-4"/>
            <display value="Explanation of benefits"/>
          </concept>
          <concept>
            <code value="52031-2"/>
            <display value="Explanation of benefits to subscriber"/>
          </concept>
          <concept>
            <code value="52044-5"/>
            <display value="External infusion pump attachment"/>
          </concept>
          <concept>
            <code value="103567-4"/>
            <display value="Path report IG"/>
          </concept>
          <concept>
            <code value="52064-3"/>
            <display
                     value="Worker's compensation first report of injury attachment"/>
          </concept>
          <concept>
            <code value="52045-2"/>
            <display value="Gait trainers attachment"/>
          </concept>
          <concept>
            <code value="52033-8"/>
            <display value="General correspondence attachment"/>
          </concept>
          <concept>
            <code value="11485-0"/>
            <display value="Anesthesia records"/>
          </concept>
          <concept>
            <code value="52035-3"/>
            <display value="Home health claims"/>
          </concept>
          <concept>
            <code value="52036-1"/>
            <display value="Home health prior authorization"/>
          </concept>
          <concept>
            <code value="52046-0"/>
            <display value="Hospital beds attachment"/>
          </concept>
          <concept>
            <code value="52032-0"/>
            <display value="Appeal denial letter"/>
          </concept>
          <concept>
            <code value="52047-8"/>
            <display value="Immunosuppressive drug attachment"/>
          </concept>
          <concept>
            <code value="77600-5"/>
            <display value="Interval note"/>
          </concept>
          <concept>
            <code value="94093-2"/>
            <display value="Itemized bill"/>
          </concept>
          <concept>
            <code value="15508-5"/>
            <display value="Labor and delivery records"/>
          </concept>
          <concept>
            <code value="11502-2"/>
            <display value="Laboratory report"/>
          </concept>
          <concept>
            <code value="52048-6"/>
            <display value="Lymphedema pump attachment"/>
          </concept>
          <concept>
            <code value="52049-4"/>
            <display value="Manual wheelchair attachment"/>
          </concept>
          <concept>
            <code value="11503-0"/>
            <display value="Medical records"/>
          </concept>
          <concept>
            <code value="28011-5"/>
            <display value="Emergency department Medical records"/>
          </concept>
          <concept>
            <code value="94118-7"/>
            <display value="Medical records in response to authorization denial"/>
          </concept>
          <concept>
            <code value="52037-9"/>
            <display value="Member ID card copy"/>
          </concept>
          <concept>
            <code value="52065-0"/>
            <display value="Automobile liability attachment"/>
          </concept>
          <concept>
            <code value="52050-2"/>
            <display value="Motorized wheelchair attachment"/>
          </concept>
          <concept>
            <code value="76641-0"/>
            <display value="Neurology study"/>
          </concept>
          <concept>
            <code value="52072-6"/>
            <display value="Non-emergency transportation attachment"/>
          </concept>
          <concept>
            <code value="53246-5"/>
            <display value="Non-medical services attachment"/>
          </concept>
          <concept>
            <code value="52066-8"/>
            <display
                     value="Notice of Discharge Medicare Appeal Rights (NODMAR) form"/>
          </concept>
          <concept>
            <code value="53244-0"/>
            <display value="Notice of privacy practices receipt"/>
          </concept>
          <concept>
            <code value="52051-0"/>
            <display value="Orthotic/Prosthetic attachment"/>
          </concept>
          <concept>
            <code value="52052-8"/>
            <display value="Osteogenesis stimulator attachment"/>
          </concept>
          <concept>
            <code value="52053-6"/>
            <display value="Oxygen attachment"/>
          </concept>
          <concept>
            <code value="52054-4"/>
            <display value="Parenteral nutrition attachment"/>
          </concept>
          <concept>
            <code value="52067-6"/>
            <display value="Past filing limit justification"/>
          </concept>
          <concept>
            <code value="52034-6"/>
            <display value="Payer letter"/>
          </concept>
          <concept>
            <code value="28629-4"/>
            <display value="Perimetry study"/>
          </concept>
          <concept>
            <code value="74030-8"/>
            <display value="Periodontal service attachment"/>
          </concept>
          <concept>
            <code value="28633-6"/>
            <display value="Polysomnography (sleep) study"/>
          </concept>
          <concept>
            <code value="52055-1"/>
            <display value="Power operated vehicle attachment"/>
          </concept>
          <concept>
            <code value="57073-9"/>
            <display value="Prenatal records"/>
          </concept>
          <concept>
            <code value="52041-1"/>
            <display value="Blood glucose monitor attachment"/>
          </concept>
          <concept>
            <code value="52068-4"/>
            <display value="Property and casualty state mandated forms"/>
          </concept>
          <concept>
            <code value="52075-9"/>
            <display value="Purchase invoice"/>
          </concept>
          <concept>
            <code value="18823-5"/>
            <display value="Alcohol and/or substance abuse service attachment"/>
          </concept>
          <concept>
            <code value="18824-3"/>
            <display value="Cardiac service attachment"/>
          </concept>
          <concept>
            <code value="18825-0"/>
            <display value="Medical social services attachment"/>
          </concept>
          <concept>
            <code value="18826-8"/>
            <display value="Occupational therapy service attachment"/>
          </concept>
          <concept>
            <code value="19002-5"/>
            <display value="Physical therapy service attachment"/>
          </concept>
          <concept>
            <code value="18594-2"/>
            <display value="Psychiatric service attachment"/>
          </concept>
          <concept>
            <code value="52184-9"/>
            <display value="Pulmonary therapy service attachment"/>
          </concept>
          <concept>
            <code value="19003-3"/>
            <display value="Respiratory therapy service attachment"/>
          </concept>
          <concept>
            <code value="29206-0"/>
            <display value="Speech therapy service attachment"/>
          </concept>
          <concept>
            <code value="52056-9"/>
            <display value="Repair of durable medical equipment attachment"/>
          </concept>
          <concept>
            <code value="52057-7"/>
            <display value="Seat lift mechanism attachment"/>
          </concept>
          <concept>
            <code value="52058-5"/>
            <display value="Seating system attachment"/>
          </concept>
          <concept>
            <code value="52039-5"/>
            <display value="Skilled Nursing Facility (SNF) record"/>
          </concept>
          <concept>
            <code value="101657-5"/>
            <display
                     value="Special investigation unit (SIU) medical record request Document"/>
          </concept>
          <concept>
            <code value="52059-3"/>
            <display value="Speech generating device attachment"/>
          </concept>
          <concept>
            <code value="52060-1"/>
            <display value="Standers/standing frame attachment"/>
          </concept>
          <concept>
            <code value="52038-7"/>
            <display
                     value="Subscriber Information including retroactive and presumptive eligibility"/>
          </concept>
          <concept>
            <code value="52061-9"/>
            <display value="Support surface attachment"/>
          </concept>
          <concept>
            <code value="52069-2"/>
            <display value="Tax ID number - IRS form W9"/>
          </concept>
          <concept>
            <code value="103595-5"/>
            <display value="Certificate of Medical Necessity"/>
          </concept>
          <concept>
            <code value="103596-3"/>
            <display value="Durable medical equipment proof of delivery receipt"/>
          </concept>
          <concept>
            <code value="103597-1"/>
            <display value="Pain management form or template"/>
          </concept>
          <concept>
            <code value="46212-7"/>
            <display value="Pre operative photo"/>
          </concept>
          <concept>
            <code value="52459-5"/>
            <display value="CMS certification number (CCN) Provider"/>
          </concept>
        </include>
      </compose>
    </ValueSet>