Form 143 Adult Heart and HeartLung Status 4 Initial Justification

Adult Heart and HeartLung Status 4 Initial Justification Form Medical Urgency Data
Fields to be completed by members
Form Section	Field Label	Notes
Status 4 Justification Form Section IV	Dischargeable left ventricular assist device (LVAD) without discretionary 30 days
Status 4 Justification Form Section IV	Inotropes without hemodynamic monitoring
Status 4 Justification Form Section IV	Dobutamine
Status 4 Justification Form Section IV	Dobutamine - Date of Initiation
Status 4 Justification Form Section IV	Milrinone
Status 4 Justification Form Section IV	Milrinone - Date of Initiation
Status 4 Justification Form Section IV	Epinephrine
Status 4 Justification Form Section IV	Epinephrine - Date of Initiation
Status 4 Justification Form Section IV	Dopamine
Status 4 Justification Form Section IV	Dopamine - Date of Initiation
Status 4 Justification Form Section IV	Cardiac index
Status 4 Justification Form Section IV	Cardiac index - Test Date
Status 4 Justification Form Section IV	Pulmonary capillary wedge pressure
Status 4 Justification Form Section IV	Pulmonary capillary wedge pressure - Test Date
Status 4 Justification Form Section IV	Congenital heart disease
Status 4 Justification Form Section IV	Congenital heart disease - Other
Status 4 Justification Form Section IV	Ischemic heart disease with intractable angina
Status 4 Justification Form Section IV	Amyloidosis, or hypertrophic or restrictive cardiomyopathy
Status 4 Justification Form Section IV	Candidate is diagnosed with at least one of the following
Status 4 Justification Form Section IV	Candidate meets at least one of the following requirements
Status 4 Justification Form Section IV	New York Heart Association (NYHA) Class III-IV symptoms
Status 4 Justification Form Section IV	Retransplant
Status 4 Justification Form Section IV	Exception for status 4
Status 4 Justification Form Section IV	Clinical Narrative
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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