Download Cryosurgical Ablation of Tumors outside the Liver

REVIEW REQUEST FOR
Cryosurgical Ablation of Solid Tumors Outside the
Liver
Provider Data Collection Tool Based on Medical Policy SURG.00025
Policy Last Review Date: 05/15/14
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 07/15/2014
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 Code(s) (if known):
Please check all that apply to the individual:
Request is for cryosurgical ablation in an individual with prostate cancer
Request is for cryosurgical ablation in an individual with clinically localized, suspected renal malignancy (Check all that
apply)
Individual has peripheral lesions
Lesions are less than or equal to 4 cm in diameter
Lesions are in a single kidney
Individual has renal insufficiency as evidenced by Glomerular filtration rate (GFR) less than or equal to
60mL/min/m2
Individual is considered a high-risk surgical candidate
Other (please list): ________________
Request is for cryosurgical ablation in an individual with benign breast tumor(s)
Request is for cryosurgical ablation in an individual with malignant breast tumor(s)
Request is for cryosurgical ablation in an individual with pancreatic cancer
Other (please list): ________________
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REVIEW REQUEST FOR
Cryosurgical Ablation of Solid Tumors Outside the
Liver
Provider Data Collection Tool Based on Medical Policy SURG.00025
Policy Last Review Date: 05/15/14
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 07/15/2014
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 the health plan or its
designees 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
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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