Download Carotid, Vertebral, Intracranial Artery Angioplasty

REVIEW REQUEST FOR
Carotid, Vertebral and Intracranial Artery Angioplasty
with or without Stent Placement
Provider Data Collection Tool Based on Medical Policies 7.01.68; Surg.00001
Policy Last Review Date: 12/2009; 11/18/2010
Policy Effective Date: 12/2009; 11/18/2010
Provider Tool Effective Date: 03/30/2011
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:
Request is for
Extracranial carotid artery angioplasty and stent placement (CAS) performed in conjunction with an FDA approved carotid
stent system
Extracranial carotid artery angioplasty without stent placement
Carotid artery angioplasty and stent placement (CAS)
Percutaneous Angioplasty (PTA) with associated stenting
Percutaneous Angioplasty (PTA) without stenting
Other (please list):
Check all that apply to the individual:
Individual can be safely treated by this approach
Individual has angiographically visible intraluminal thrombus
Individual has no angiographically visible intraluminal thrombus
Individual has: (Check all that apply)
Symptomatic stenosis equal to or greater than 50%
Asymptomatic stenosis equal to or greater than 80%
Complete occlusion (100% stenosis) of the relevant carotid artery
Symptomatic stenosis less than 50% of the relevant carotid artery
Asymptomatic stenosis less than 80% of the relevant carotid artery
Contralateral laryngeal nerve palsy
Existence of lesions distal or proximal to the carotid bulb and bifurcation of the common carotid
Radiation-induced stenosis following previous radiation therapy to the neck or radical neck dissection
Restenosis after carotid endarterectomy (CEA)
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REVIEW REQUEST FOR
Carotid, Vertebral and Intracranial Artery Angioplasty
with or without Stent Placement
Provider Data Collection Tool Based on Medical Policies 7.01.68; Surg.00001
Policy Last Review Date: 12/2009; 11/18/2010
Policy Effective Date: 12/2009; 11/18/2010
Provider Tool Effective Date: 03/30/2011
Severe tandem lesions that may require endovascular therapy
Stenosis secondary to arterial dissection
Stenosis secondary to fibromuscular dysplasia
Stenosis secondary to Takayasu arteritis
Stenosis that is surgically difficult to access (e.g., high bifurcation requiring mandibular dislocation)
Stenosis associated with contralateral carotid artery occlusion
Stenosis that cannot be safely reached or crossed by endovascular approach
Pseudoaneurysm
Inability to move the neck to a suitable position for surgery
Tracheostomy
Stenosis or aneurysm of extracranial vertebral arteries or intracranial arteries
Other (please list):
Individual is at high risk for surgery (check all that apply)
Individual has Congestive heart failure (NYHA Class III/IV)
Left ventricular ejection fraction less than 30%
Open heart surgery needed within the next 6 weeks
History of recent myocardial infarction (greater than 24 hours and less than 4 weeks)
Individual has severe chronic obstructive pulmonary disease
Individual has unstable angina (CCS class III/IV)
Other (please list):
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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