REVIEW REQUEST FOR
Cosmetic & Reconstructive Services: Skin Related
Provider Data Collection Tool Based on Medical Policy ANC.00007
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/09/12
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:
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:
Request is for chemical peel to treat (Please complete below):
Active acne
Actinic keratoses or other pre-malignant lesions with documented evidence of 10 or more lesions which have
failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy, and plan is to perform
medium or deep chemical peel
Photo-aged skin
Wrinkles
Acne scarring
Uneven epidermal pigmentation
Other condition in the absence of a significant physical functional impairment and is intended to change physical
appearance that would be considered within normal anatomic variation.
Other:
Request is for collagen injections or implants (Please complete below):
There is documented evidence of significant physical functional impairment and the procedure can be
reasonably expected to improve the physical function impairment.
There is a significant variation from the normal related to accidental injury, disease, trauma, treatment of
disease, or a congenital defect and the procedure is intended to address the significant variation from normal.
(Please describe):
Other:
Request is for dermabrasion or salabrasion to treat: (Please complete below):
Actinic keratoses, other pre-malignant skin lesions and localized non-melanoma malignant skin lesions (e.g.
basal cell carcinoma and carcinoma in-situ)
Upper layer of the skin for acne, acne scars, uneven pigmentation or wrinkles
Other condition in the absence of a significant physical functional impairment and is intended to change physical
appearance that would be considered within normal anatomic variation.
Other:
Request is for laser or surgical treatment of rosacea and telangiectasia (Please complete below):
Individual has isolated telangiectasia
Individual has severe, refractory form of rosacea that is unresponsive to standard medical therapy and
preoperative photos document the clinical skin changes requiring treatment. *** Please attach photos.
Other:
Request is for tattooing of the skin (Please complete below):
Individual requires tattoing of the skin as part of a medically necessary therapeutic treatment. (for example, but
not limited to, tattooing related to radiation therapy.
Tattooing of the skin performed as a part of a covered breast reconstruction.
Other:
Request is for the injection of dermal fillers, such as poly-L-lactic acid (PLLA), or synthetic calcium hydroxylapatite
(Please complete below):
There is a significant variation from the normal related to accidental injury, disease, trauma, treatment of
disease, or a congenital defect and the procedure is intended to address the significant variation from normal.
(Please describe):
Other:
Request is for the treatment of cutaneous hemangioma, port wine stain or other vascular lesion (Please complete below):
There is documented evidence of significant physical functional impairment (for example, bleeding or a lesion
which interferes with vision) and the procedure can be reasonably expected to improve the physical functional
impairment.
There is a significant variation from the normal related to a congenital defect and the procedure is intended to
restore appearance and address the significant variation from normal.
Other:
Request is for a hair procedure (Please complete below):
Permanent removal of hair related to a recurrent infected cyst, hair follicle infections or after surgical treatment
of pilonidal sinus disease.
Hairplasty for alopecia
Temporary or permanent removal of hair using lasers, electrolysis or waxing
Other:
Request is for any of the following:
Laser skin resurfacing
Removal or excision of a tattoo.
Other:
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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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