REVIEW REQUEST FOR
Treatment for Urinary Incontinence and
Urinary Retention
Provider Data Collection Tool Based on Coverage Guideline SURG.00010
Policy Last Review Date: 02/05/2015
Policy Effective Date:
04/07/2015
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
04/07/2015
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 note the following Clinical Data Submission Tools to ensure the request is submitted on
the correct tool
 CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
 SURG.00117 Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and
Fecal Incontinence; Urinary Retention
Please check all that apply to the member
Please complete this form in its entirety to facilitate the requested review
Request is for Implantation of an artificial urinary sphincter device to treat ISD:
(Check the following that apply to this individual)
Individual is a woman whose incontinence has been refractory to conservative medical treatment or
other surgical treatments
Individual is a child whose incontinence has been refractory to conservative medical treatment or other
surgical treatments
Individual is a male who has not undergone prostate surgery
Request is for vaginal weight training with specially designed weights (cones) as a treatment of urinary incontinence
Request is for transvaginal radiofrequency bladder neck suspension as a treatment of urinary stress incontinence
Request is for transurethral radiofrequency energy collagen micro-remodeling as a treatment of stress urinary incontinence
Page 1 of 2
REVIEW REQUEST FOR
Treatment for Urinary Incontinence and
Urinary Retention
Provider Data Collection Tool Based on Coverage Guideline SURG.00010
Policy Last Review Date: 02/05/2015
Policy Effective Date:
04/07/2015
Provider Tool Effective Date:
04/07/2015
Request is for the injection of periurethral bulking agents for the treatment of urinary incontinence
(If check, complete below)
Individual has stress urinary incontinence (SUI) caused by intrinsic sphincter deficiency (ISD) which
persists despite at least 12 consecutive months of conventional therapy (for example, exercise, medication);
Individual has a post-traumatic or post-surgical injury
Urethral hypermobility in a female with abdominal leak point less than 100 cm H20 which persists
despite at least 12 consecutive months of conventional therapy (for example, exercise, medication)
Other (please describe):
Request is for implantation of an artificial urinary sphincter device in a male individual following prostate surgery
(If checked, answer the following that apply)
The device is being used as a first line treatment* of refractory incontinence
The device is being used to treat urinary incontinence due to reduce outlet resistance (Intrinsic Sphincter
Deficiency [ISD])
Iindividual’s symptoms of incontinence have been refractory to at least 6 months of conservative
medical treatment.*
*Note: Examples of first-line conservative medical treatment: behavioral therapy, pharmacologic treatments, and
intermittent self-catheterization.
Indication other than those listed above (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 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.
Page 2 of 2