Download Wearable Cardioverter Defibrillators

REVIEW REQUEST FOR
Wearable Cardioverter Defibrillators
Provider Data Collection Tool Based on Coverage Guideline MED.00055
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 09/29/2010
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 Code(s) (if known):
Please check all that apply to the individual:
Request is for a wearable cardioverter defibrillator (WCD) for an individual at high risk for sudden cardiac arrest
(If checked, you must complete and submit this document as well as the Clinical Data Submission Tool – SURG.00033
Implantable Cardioverter-Defibrillator (ICD) ***)
Individual had a previously implanted ICD that requires explantation due to infection with waiting period before
ICD reinsertion
Individual has an infection process or other temporary condition that precludes initial implantation of an ICD
Individual is awaiting a heart transplantation - on a waiting list and meets medical necessity criteria
Individual has drug-refractory class IV congestive heart failure (CHF) and is not a candidate for heart transplantation
Individual has had an acute myocardial infarction (MI) within the last 40 days
Individual has a history of psychiatric disorders that interfere with the necessary care and follow-up
Individual has a reversible triggering factor for VT/VF that can be definitely identified, such as ventricular tachyarrythmias
in evolving acute myocardial infarction or electrolyte abnormalities
Individual has a terminal illness
Other (Please list):
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REVIEW REQUEST FOR
Wearable Cardioverter Defibrillators
Provider Data Collection Tool Based on Medical Policy MED.00055
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 09/29/2010
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
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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