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: 11/18/10
Policy Effective Date: 11/18/10
Provider Tool Effective Date: 03/09/2012
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:
Cochlear Implants
Request is for unilateral cochlear implantation
Request is for 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 of 70 decibels (dB) or greater.
Individual cannot benefit from conventional hearing devices
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 rehabilitation program
Other: (please describe)
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)
Upgrade/replacement is for convenience
Upgrade/replacement is to upgrade to a newer technology when the current components remain functional.
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.
Other: (please describe)
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 has Neurofibromatosis Type II
Individual is completely deaf as a result of the bilateral resection of 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
Upgrade/replacement is for convenience
Upgrade/replacement is to upgrade to a newer technology when the current components remain functional.
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.
Other: (please describe)
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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