Download Cardiac Resynchronization Therapy

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: 11/05/2015
Policy Effective Date:
01/05/2016
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):
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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: 11/05/2015
Policy Effective Date:
01/05/2016
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.
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