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The payer questions medical necessity

Limits of the workup A B12 value alone neither confirms nor excludes malignancy, and clinical judgment decides whether to observe, repeat, evaluate further, or refer

Medications on the formulary may change Most changes in drug coverage happen on January 1, but we may add or remove drugs on the drug list during the year, move them to different cost-sharing tiers, or add new restrictions

The clinical record must clearly demonstrate the providers active oversight and the medical necessity of the prolonged treatment

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