Download Cochlear and Auditory Brainstem Implants

REVIEW REQUEST FOR
Cochlear & Auditory Brainstem Implants
Provider Data Collection Tool Based on Medical Policy SURG.00014
Policy Last Review Date:
08/04/2016
Policy Effective Date:
08/18/2016
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
08/18/2016
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 Code(s) (if known):
Please check all that apply to the individual:
Cochlear Implants
The cochlear implant will be used to treat an auditory neuropathy spectrum disorder (ANSD)
The cochlear implant will be used to treat tinnitus
The cochlear implant will be used to treat unilateral deafness
Request is for a unilateral cochlear implantation
Request is for a bilateral cochlear implantation
Request is for an FDA-approved single channel cochlear implant
Request is for an FDA-approved multi-channel cochlear implant
Other: (please describe)
Initial Request:
Individual has bilateral severe-to-profound pre- or postlingual hearing loss (sensorineural deafness) defined as a hearing
threshold pure tone average (PTA) of 70 decibels (dB) or greater.
Individual has obtained limited benefit from conventional hearing aids
Individual is free from lesions in the auditory nerve and acoustic areas of the central auditory pathway (nervous system)
Individual is free from otitis media or other active middle ear infections
Individual is able to participate in a post-cochlear implant rehabilitation program
Other: (please describe)
Subsequent Request:
Request is for a subsequent bilateral implantation (that is, sequential implantation)
Check all of the following conditions that applied to the individual at the time of initial (first) cochlear implantation:
Individual had bilateral severe to profound pre- or postlingual hearing loss (sensorineural deafness) defined as a
hearing threshold pure tone average (PTA) of 70 decibels (dB) or greater.
Individual had obtained limited benefit from conventional hearing aids
Individual was free from lesions in the auditory nerve and acoustic areas of the central auditory pathway
(nervous system)
Individual was free from otitis media or other active middle ear infections
Individual was able to participate in a post-cochlear implant rehabilitation program
Upgrade/Replacement request: **Please mark type of implant above**
Request is for upgrade to or replacement of an existing external speech processor, controller or speech processor
and controller (integrated system) (If checked, mark all of the following conditions that apply)
Individual’s response to existing component is inadequate to the point of interfering with activities of daily living
Components of current device are no longer functional
Upgrade/replacement is for convenience
Upgrade/replacement is to upgrade to a newer technology when the current components remain functional.
Other: (please describe)
Hybrid Cochlear Implant
Request is for an approved hybrid cochlear implant (for example, Nucleus® Hybrid™ L24 Cochlear Implant
System) (If checked, mark all of the following conditions that apply)
Individual is 18 years of age or older with bilateral severe-to-profound high-frequency sensorineural hearing loss
with residual low-frequency hearing sensitivity (that is, able to hear low-frequency sounds)
Individual has obtained limited benefit from bilateral hearing aids
Individual has normal-to-moderate hearing loss in the low-frequencies (that is, hearing thresholds no poorer
than 60 dB hearing level up to and including 500 Hz, averaged over 125, 250, and 500 Hz) in the ear selected for
implantation
Individual has severe-to-profound mid- to high-frequency hearing loss (threshold average of 2000, 3000,
and 4000 Hz equal to or greater than 75 dB hearing level) in the ear to be implanted
Individual has moderately severe to profound mid- to high-frequency hearing loss (threshold average of 2000,
3000, and 4000 Hz greater than or equal to 60 dB hearing level) in the contralateral ear
Individual’s preoperative speech perception scores demonstrate Consonant-Nucleus-Consonant (CNC) word
recognition score from 10% to 60% in the ear to be implanted
Individual’s preoperative speech perception scores demonstrate CNS word recognition score in the contralateral ear
equal to or better than in the ear to be implanted, but not more than 80% in the best-aided condition
Individual is free from otitis media or other active middle ear infections
Individual is able to participate in a post-hybrid cochlear implant rehabilitation program in order to achieve benefit
from the hybrid cochlear implant device
Auditory Brain Stem Implants
Request is for an FDA-approved auditory brainstem implant (ABI)
Other: (please describe)
Initial Request:
Individual is 12 years of age or older
Individual is diagnosed with Neurofibromatosis Type II
Individual is completely deaf as a result of bilateral neurofibromas of the auditory nerve
Other: (please describe)
Upgrade/Replacement Request: **Please mark type of implant above**
Request is for upgrade to or replacement of an existing external sound processor, remote assistant or both components
(Please check 1 of the following reasons for Upgrade/Replacement request)
Individual’s response to existing component is inadequate to the point of interfering with activities of daily living
Components of current device are no longer functional.
Upgrade/replacement is for convenience
Upgrade/replacement is to upgrade to a newer technology when the current components remain functional.
Other: (please describe)
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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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