Download ICD - Anthem

REVIEW REQUEST FOR
Implantable Cardioverter-Defibrillator (ICD)
Provider Data Collection Tool Based on Medical Policies 7.01.44; SURG.00033
Policy Last Review Date: 12/2009; 11/18/2010
Policy Effective Date: 11/2009; 12/01/2010
Provider Tool Effective Date: 03/09/2011
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the individual:
ADULT INDICATIONS
Request is for implantable cardioverter-defibrillator (ICD) therapy in an adult
Request is for ICD/Biventricular pacing (CRT/ICD) device (*** If checked, you must complete and submit this
document as well as the Clinical Data Submission Tool - Cardiac Resyncronizing Therapy (CRT) with or without an
Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure ***)
Request is to treat ventricular tachyarrhythmias and to prevent sudden cardiac death (SCD)
Individual is receiving optimal medical therapy
Individual has a reasonable expectation of survival with a good functional status for more than 1 year
Individual had cardiac arrest due to ventricular fibrillation (VF) or hemodynamically unstable sustained ventricular
tachycardia (VT), an evaluation to define the cause of the event has been done, and any completely reversible causes of the
cardiac arrest have been excluded
Individual has structural heart disease and spontaneous sustained ventricular tachycardia (VT)
Individual has syncope of undetermined origin with either clinically relevant, hemodynamically significant sustained
ventricular tachycardia (VT) or ventricular fibrillation (VF) induced at electrophysiological study
Individual with long-QT syndrome who is experiencing syncope or VT while receiving beta blockers
Individual has a Left Ventricular Ejection Fraction (LVEF) less than 35% due to a prior myocardial infarction (MI) that
occurred at least 40 days ago.
Individual has nonischemic dilated cardiomyopathy (NIDCM) with an LVEF less than or equal to 35%
Individual has nonsustained VT due to a prior MI, LVEF less than 40% and inducible VF or sustained VT at
electrophysiological study
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REVIEW REQUEST FOR
Implantable Cardioverter-Defibrillator (ICD)
Provider Data Collection Tool Based on Medical Policy SURG.00033
Policy Last Review Date: 11/18/2010
Policy Effective Date: 12/01/2010
Provider Tool Effective Date: 12/01/2010
Individual has ischemic cardiomyopathy, has not had an MI in the past 40 days and has an LVEF less than 30% (if checked
please complete below)
Individual has left ventricular systolic dysfunction associated with marked stenosis (at least 75% narrowing) of at
least 1 of the 3 coronary arteries
Individual has a documented history of myocardial infarction
Individual has confirmed hypertrophic cardiomyopathy (HCM) with two (2) or more major risk factors for sudden cardiac
death (if checked please complete below)
Family history of HCM-related SCD in at least 1 first-degree relative
At least 1 episode of unexplained syncope within the previous 12 months
Nonsustained VT on ECG
Abnormal blood pressure (BP) response during upright exercise testing
Left Ventricular (LV) wall thickness greater than or equal to 30 mm
Other (Please list):
Other (Please list):
*** MUST BE COMPLETED***
Please classify the individual according to the New York Heart Association (NYHA) definitions:
CLASS I – Individual with cardiac disease but without resulting limitation of physical activity; ordinary physical activity
does not cause undue fatigue, palpitation , dyspnea, or anginal pain; symptoms only occur on severe exertion
CLASS II – Individual has cardiac disease resulting in slight limitation of physical activity; they are comfortable at rest;
ordinary physical activity (e.g., moderate physical exertion, such as carrying shopping bags up several flights of stairs) result in
fatigue, palpitation, dyspnea, or anginal pain.
CLASS III – Individual has cardiac disease resulting in marked limitation of physical activity; they are comfortable at rest;
less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain.
CLASS IV – Individual has cardiac disease resulting in the inability to carry on any physical activity without discomfort;
symptoms of heart failure or the anginal syndrome may be present even at rest; if any physical activity is undertaken,
discomfort is increased.
PEDIATRIC INDICATIONS
Request is for implantable cardioverter-defibrillator (ICD) therapy in a pediatric individual
Request is for ICD/Biventricular pacing (CRT/ICD) device (*** If checked, you must complete and submit this
document as well as the Clinical Data Submission Tool - SURG.00064 Cardiac Resyncronizing Therapy (CRT) with or
without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure ***)
Request is to treat ventricular tachyarrhythmias and to prevent sudden cardiac death (SCD)
Individual is receiving optimal medical therapy
Individual has a reasonable expectation of survival with a good functional status for more than 1 year
Individual is a survivor of cardiac arrest, has been evaluated and any reversible causes of the event have been excluded
Individual has symptomatic sustained ventricular tachycardia (VT) in association with congenital heart disease and has
undergone hemodynamic and electrophysiological evaluation
Individual has congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular
dysfunction or inducible ventricular arrhythmias at electrophysiological study
Other (Please list):
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REVIEW REQUEST FOR
Implantable Cardioverter-Defibrillator (ICD)
Provider Data Collection Tool Based on Medical Policy SURG.00033
Policy Last Review Date: 11/18/2010
Policy Effective Date: 12/01/2010
Provider Tool Effective Date: 12/01/2010
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a
routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
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