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REVIEW REQUEST FOR Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Provider Data Collection Tool Based on Medical Policy SURG.00064 Policy Last Review Date: 11/13 2014 Policy Effective Date: 11/17/2014 Provider Tool Effective Date: 11/17 2014 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 FDA-approved biventricular pacemaker for cardiac resynchronization therapy (CRT) Request is for a FDA-approved ICD, in combination with cardiac resynchronization therapy (CRT/ICD) (*** If checked, you must complete and submit this document as well as the Clinical Data Submission Tool - SURG.00033 Implantable Cardioverter-Defibrillator (ICD) ***) Individual has NYHA functional Class II, Class III, or ambulatory Class IV symptoms, secondary to heart failure who remain symptomatic despite recommended, optimal medical therapy Individual has a left bundle branch block (LBBB) morphology and QRS duration of 120-149 ms Individual has any QRS morphology and QRS duration greater than or equal to 150 ms Individual’s left ventricular ejection fraction (LVEF) less than or equal to 35% Individual is in sinus rhythm. Individual is in atrial fibrillation and AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing The NYHA functional status and ejection fraction were measured after a 3 month trial of optimal medical therapy NOTE to provider: Optimal medical therapy, now referred to as “Guideline-directed medical therapy” (GDMT), may include use of the following medications either individually or in combination, unless contraindicated: angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers, digoxin, diuretics, and aldosterone antagonists, when appropriate. Other (Please list): Other (Please list): Page 1 of 2 REVIEW REQUEST FOR Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Provider Data Collection Tool Based on Medical Policy SURG.00064 Policy Last Review Date: 11/13 2014 Policy Effective Date: 11/17/2014 Provider Tool Effective Date: 11/17 2014 *** MUST BE COMPLETED*** Please classify the individual according to the New York Heart Association (NYHA) definitions: CLASS I – Individual with cardiac disease but without resulting limitation of physical activity; ordinary physical activity does not cause undue fatigue, palpitation , dyspnea, or anginal pain; symptoms only occur on severe exertion CLASS II – Individual has cardiac disease resulting in slight limitation of physical activity; they are comfortable at rest; ordinary physical activity (e.g., moderate physical exertion, such as carrying shopping bags up several flights of stairs) results in fatigue, palpitation, dyspnea, or anginal pain. CLASS III – Individual has cardiac disease resulting in marked limitation of physical activity; they are comfortable at rest; less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain. CLASS IV – Individual has cardiac disease resulting in the inability to carry on any physical activity without discomfort; symptoms of heart failure or the anginal syndrome may be present even at rest; if any physical activity is undertaken, discomfort is increased. 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 the health plan or its designees 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. Page 2 of 2