Download Stereotactic Radiosurgery (SRS)

REVIEW REQUEST FOR
Stereotactic Radiosurgery (SRS) and Stereotactic
Body Radiotherapy (SBRT)
Provider Data Collection Tool Based on Coverage Guideline SURG.00017
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/01/2015
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 stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (performed more than one time on a
specific site) for the treatment of cranial lesions (If checked, please complete below)
Intracranial arteriovenous malformation (AVM)
Acoustic neuroma
Pituitary adenoma (Cushing's disease or acromegaly)
Meningioma, non-resectable, residual, or recurrent
Craniopharyngioma
Pineal gland neoplasm
Uveal melanoma
High-grade glioma (initial treatment or treatment of recurrence)
Trigeminal neuralgia refractory to medical management
Schwannomas
Brain metastases from any non-brain primary site when the individual has a performance status greater than or
equal to 70% on the Karnofsky Scale or less than or equal to 2 on the Eastern Cooperative Oncology Group
(ECOG) Scale
Other :
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REVIEW REQUEST FOR
Stereotactic Radiosurgery (SRS) and Stereotactic
Body Radiotherapy (SBRT)
Provider Data Collection Tool Based on Coverage Guideline SURG.00017
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/01/2015
Request is for stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (performed more than one time
on a specific site) for the treatment of primary or recurrent tumors within the spine, OR metastases to the spine
from other primary sites (If checked, please complete below)
Tumor not amenable to surgery (for example, due to prior surgery, tumor location, or
individual ability to withstand surgery)
Tumor not amenable to conventional radiation therapy (for example, stereotactic precision is
required to avoid unacceptable radiation to unaffected tissues)
Other :
Request is for stereotactic body radiotherapy (SBRT) or fractionated stereotactic radiotherapy (performed more than
one time on a specific site) for the treatment of non-small cell lung cancer (NSCLC) (If checked, please complete below)
Single lesion less than or equal to 5 cm
Lesion is inoperable based on tumor location or individual is not a surgical candidate because
of medical contraindication (for example, limited pulmonary reserve)
Procedure is done for a curative intent [staging – no known distant metastasis (M0); No metastasis to
regional lymph nodes (N0)]
Other :
Request is for stereotactic body radiotherapy (SBRT) or fractionated stereotactic radiotherapy (performed more than
one time on a specific site) for the treatment of metastatic cancer in the lung (If checked, please complete below)
Single lesion less than or equal to 5 cm
Individual has a performance status greater than or equal to 70% on the Karnofsky Scale or
less than or equal to 2 on the ECOG Scale
Any extracranial disease is stable
The procedure is being performed with curative intent or to palliate a symptomatic (for example, pain or
hemoptysis) lesion
Other:
Request is for stereotactic body radiotherapy (SBRT) or fractionated stereotactic radiotherapy (performed more than
one time on a specific site) as a palliative treatment for an individual with specific liver-related symptoms due to
tumor bulk (for example, pain) from any primary or metastatic hepatic tumor.
Request is for stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT) or fractionated stereotactic
radiotherapy (performed more than one time on a specific site) for palliative treatment of an individual with
spinal metastases.
Request is for stereotactic body radiotherapy (SBRT) or fractionated stereotactic radiotherapy (performed more than
one time on a specific site) in an individual who requires repeat irradiation of a field that has received prior irradiation.
Request is for stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT) or fractionated stereotactic
radiotherapy (performed more than one time on a specific site) for: (If checked, please complete below)
Chronic pain
Psychoneurosis
Epilepsy
Parkinson's disease & other movement disorders (e.g. tremor)
Primary or metastatic cancers of the kidney, liver, colon and pancreas and
brain metastases is NOT involved
Treatment of functional disorders other than trigeminal neuralgia
Other:
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REVIEW REQUEST FOR
Stereotactic Radiosurgery (SRS) and Stereotactic
Body Radiotherapy (SBRT)
Provider Data Collection Tool Based on Coverage Guideline SURG.00017
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/01/2015
Request is for stereotactic body radiostherapy (SBRT), for prostate cancer ( more than one time on a specific site):
(If checked, please complete below)
Low grade prostate cancer defined by a Gleason less than or equal to 6 and
prostate-specific antigen (PSA) less than 10 ng/mL
Minimal disease defined as less than four cores positive
No evidence of extraprostatic disease
Life expectancy of greater than 10 years.
Other :
Other :
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 Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life
and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a
registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered
marks of the Blue Cross Association. For some plans utilization review services are provided by Anthem UM
Services, Inc., a separate company.
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