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REVIEW REQUEST FOR Vagus Nerve Stimulation Provider Data Collection Tool Based on Anthem Medical Policies SURG.00007 Policy Last Review Date: 11/17/2011 Policy Effective Date: 01/11/2012 Provider Tool Effective Date: 03/7/2012 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: Request is for the implantation of a vagus nerve stimulation device Request is for an electronic analysis of an implanted neurostimulator pulse generator system for vagus nerve stimulation Individual has medically and surgically refractory seizures Individual has failed more than one trial of single or combination anti-epileptic medications, as evidenced by persistent seizures or intolerable side effects of drug therapy Individual has failed or is not a candidate for resective epilepsy surgery Request is to treat individual’s for these following conditions: (if checked, please complete below) Alzheimer's disease Anxiety and mood disorders Autism Bipolar disorders Bulimia Cerebral palsy Depression Essential tremors Fibromyalgia Headaches (including cluster and migraine headaches) Obesity Seizures (that do not meet the medically necessary criteria) Sleep disorders Other: (please describe): Other: (please describe): Page 1 of 2 REVIEW REQUEST FOR Vagus Nerve Stimulation Provider Data Collection Tool Based on Anthem Medical Policies SURG.00007 Policy Last Review Date: 11/17/2011 Policy Effective Date: 01/11/2012 Provider Tool Effective Date: 03/7/2012 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 Page 2 of 2