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REVIEW REQUEST FOR Deep Brain Stimulation Provider Data Collection Tool Based on: Medical Policy Reference Manual 7.01.63 Medical Policy SURG.00026 Provider Tool Effective Date: 3/2/2011 Policy Last Review Date: Feb 2009 Policy Effective Date Feb 2009 Policy Last Review Date: 05/13/2010 Policy Effective Date: 0707/2010 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 unilateral or bilateral deep brain stimulation to the thalamus for the treatment of a medically refractory essential tremor or Parkinson’s disease. Request is for unilateral or bilateral deep brain stimulation of the subthalamic nucleus or globus pallidus for an individual with primary dystonia (check all that apply): Parkinson disease (check all that apply): A good response to levodopa Individual has a minimal score of 30 points on the motor portion of the Unified Parkinson's Disease Rating Scale when the individual was not on medication for 12 hours prior to the test Individual has motor complications of therapy that cannot be controlled pharmacologically Other (please list): Individual is seven (7) years of age or older Page 1 of 2 REVIEW REQUEST FOR Deep Brain Stimulation Provider Data Collection Tool Based on: Medical Policy Reference Manual 7.01.63 Medical Policy SURG.00026 Provider Tool Effective Date: 3/2/2011 Policy Last Review Date: Feb 2009 Policy Effective Date Feb 2009 Policy Last Review Date: 05/13/2010 Policy Effective Date: 0707/2010 The dystonia is chronic, refractory to drugs, and has a significant effect upon daily activity The dystonia is NOT due to secondary causes such as stroke, cerebral palsy, tumor, trauma, infection, multiple sclerosis, other neurodegenerative diseases or medications The dystonia manifests as one or more of the following (check all that apply): Cervical dystonia (torticollis) Segmental dystonia Generalized dystonia Hemidystonia Other (please list): Request is for unilateral or bilateral deep brain stimulation for tremors & dystonia as the result of (check all that apply): trauma multiple sclerosis degenerative disorders metabolic disorders infectious diseases drug induced movement tardive dyskinesia Other (please list): Request is for unilateral or bilateral deep brain stimulation for the treatment of (check all that apply): epilepsy chronic cluster headaches obsessive-compulsive disorder (OCD). Tourette syndrome depression Other (please list): Request is for cerebellar stimulation/pacing. 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 Page 2 of 2