Download Deep Brain Stimulation

REVIEW REQUEST FOR
Deep Brain Stimulation
Provider Data Collection Tool
Based on:
Medical Policy Reference Manual
7.01.63
Medical Policy
SURG.00026
Provider Tool Effective Date: 3/2/2011
Policy Last Review Date: Feb 2009
Policy Effective Date Feb 2009
Policy Last Review Date: 05/13/2010
Policy Effective Date: 0707/2010
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 unilateral or bilateral deep brain stimulation to the thalamus for the treatment of a medically refractory
essential tremor or Parkinson’s disease.
Request is for unilateral or bilateral deep brain stimulation of the subthalamic nucleus or globus pallidus for an individual
with primary dystonia (check all that apply):
Parkinson disease (check all that apply):
A good response to levodopa
Individual has a minimal score of 30 points on the motor portion of the Unified Parkinson's Disease
Rating Scale when the individual was not on medication for 12 hours prior to the test
Individual has motor complications of therapy that cannot be controlled pharmacologically
Other (please list):
Individual is seven (7) years of age or older
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REVIEW REQUEST FOR
Deep Brain Stimulation
Provider Data Collection Tool
Based on:
Medical Policy Reference Manual
7.01.63
Medical Policy
SURG.00026
Provider Tool Effective Date: 3/2/2011
Policy Last Review Date: Feb 2009
Policy Effective Date Feb 2009
Policy Last Review Date: 05/13/2010
Policy Effective Date: 0707/2010
The dystonia is chronic, refractory to drugs, and has a significant effect upon daily activity
The dystonia is NOT due to secondary causes such as stroke, cerebral palsy, tumor, trauma, infection, multiple
sclerosis, other neurodegenerative diseases or medications
The dystonia manifests as one or more of the following (check all that apply):
Cervical dystonia (torticollis)
Segmental dystonia
Generalized dystonia
Hemidystonia
Other (please list):
Request is for unilateral or bilateral deep brain stimulation for tremors & dystonia as the result of (check all that apply):
trauma
multiple sclerosis
degenerative disorders
metabolic disorders
infectious diseases
drug induced movement
tardive dyskinesia
Other (please list):
Request is for unilateral or bilateral deep brain stimulation for the treatment of (check all that apply):
epilepsy
chronic cluster headaches
obsessive-compulsive disorder (OCD).
Tourette syndrome
depression
Other (please list):
Request is for cerebellar stimulation/pacing.
Other (please list):
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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