Download Transcatheter Closure of Cardiovascular Defects

REVIEW REQUEST FOR
Transcatheter Closure of Cardiovascular Defects
Provider Data Collection Tool Based on Medical Policies 7.01.61; SURG.00032
Policy Last Review Date: 07/2003; 08/19/2010
Policy Effective Date: 10/13/2010
Provider Tool Effective Date: 03/16/2011
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: (Check all that apply)
Transcatheter closure of cardiovascular defects
Transmyocardial/perventricular device closure of cardiovascular defects
Individual has: (Check all that apply)
Patent ductus arteriosus (PDA)
Patent foramen ovale (PFO) and (Check all that apply)
History of cryptogenic stroke
Has failed conventional drug therapy (e.g., warfarin)
Is not a suitable candidate for conventional drug therapy
Complex single ventricle physiology and: (Check all that apply)
Has undergone a fenestrated Fontan palliation procedure and requires closure of the fenestration
Ventricular septal defect (VSD) and the treating physician determined that the closure of the VSD is appropriate
Secundum atrial septal defect (ASD) and the treating physician determined that the closure of the ASD is
appropriate
Other (Please list):
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REVIEW REQUEST FOR
Transcatheter Closure of Cardiovascular Defects
Provider Data Collection Tool Based on Medical Policies 7.01.61; SURG.00032
Policy Last Review Date: 07/2003; 08/19/2010
Policy Effective Date: 10/13/2010
Provider Tool Effective Date: 03/16/2011
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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