Download Radiofrequency Ablation Outside Liver

REVIEW REQUEST FOR
Radiofrequency Ablation to Treat Tumors Outside the Liver
Provider Data Collection Tool Based on Anthem Medical Policy, SURG.00050
Policy Last Review Date: 05/19/2011
Policy Effective Date: 07/13/2011
Provider Tool Effective Date: 03/19/2012
Member Name:
Date of Birth:
Insurance Identification Number:
Member 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:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the member:
Request is for radiofrequency ablation of (check all that apply):
Osteoid osteomas
Painful bony metastases when: (check all that apply)
The individual has failed or is considered a poor candidate for standard treatments such as opioids or radiation
therapy
Other: ______________
Clinically localized suspected renal malignancy when: (check all that apply)
Individual has peripheral lesions in the kidney which are less than or equal to 4 cm in diameter
The individual has a single kidney
Individual’s has renal insufficiency as documented by a glomerular filtration rate (GFR) of less than or equal to
60mL/min/m2
Individual is considered a high-risk surgical candidate
Other: ______________
Biopsy-proven non-small cell lung cancer (NSCLC) when: (check all that apply)
Surgical or radiation treatment with curative intent is considered appropriate based on the stage of the disease
Individual has co-morbid conditions which render the member unfit for those interventions (surgical or radiation)
No tumor has a diameter greater than 3.0 cm
The tumors are located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches,
pulmonary artery and the heart
Other: ______________
Metastatic malignant tumor(s) to the lung when: (check all that apply)
Individual has biopsy proven lung metastasis(es) from an extra-pulmonary primary site
The treatments (surgical or radiation) are considered appropriate based on the stage of the disease
REVIEW REQUEST FOR
Radiofrequency Ablation to Treat Tumors Outside the Liver
Provider Data Collection Tool Based on Anthem Medical Policy, SURG.00050
Policy Last Review Date: 05/19/2011
Policy Effective Date: 07/13/2011
Provider Tool Effective Date: 03/19/2012
Individual has co-morbid conditions which render them unfit for those interventions (surgical or radiation).
There is no current active extra-pulmonary disease
There are no more than 3 tumors per lung
No tumor has a diameter greater than 3.0 cm
The tumors are located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches,
pulmonary artery and the heart
The request is for a repeat radiofrequency ablation procedure
At least 12 months have elapsed since the prior ablation
Other: ______________
Breast cancer
Breast fibroadenomas
Head and neck tumors
Adrenal cancer
Chordoma
Ovarian cancer
Pelvic/abdominal metastases of unspecified origin
Any other (please describe):
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