REVIEW REQUEST FOR Electrical Bone Growth Stimulation Provider Data Collection Tool Based on Medical Policy DME.00004 Policy Last Review Date: 08/06/2015 Policy Effective Date: 10/06/2015 Provider Tool Effective Date: 12/12/2015 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): This medical policy based data collection tool is for medical necessity review for the use of invasive, noninvasive, and semi-invasive electrical bone growth stimulation devices. Read carefully and make your selection appropriately. You MUST accurately complete this form specific to your request to facilitate your review request. Please check all that apply to the individual: Request is for invasive (inserted at time of surgery) electrical bone growth stimulation for spinal fusion surgery in individuals at high risk for pseudoarthrosis Request is for noninvasive (beginning from the time of surgery up to 6 months after surgery) electrical bone growth stimulation for spinal fusion surgery in individuals at high risk for pseudoarthrosis (If checked, please mark all of the following that apply to the individual) One or more previous failed spinal fusion(s) Grade III or worse spondylolisthesis Fusion to be performed at more than one level History of tobacco use History of alcoholism Diabetes where bone healing is likely to be compromised or growth is poor Renal disease where bone healing is likely to be compromised or growth is poor Metabolic disease where bone healing is likely to be compromised or growth is poor (please list disease): Nutritional deficiency Obese individual with a Body Mass Index (BMI) greater than 30 Obese individual with greater than 50% over his/her ideal body weight (IBW)* Severe anemia Steroid therapy Other (please list): REVIEW REQUEST FOR Electrical Bone Growth Stimulation Provider Data Collection Tool Based on Medical Policy DME.00004 Policy Last Review Date: 08/14/2014 Policy Effective Date: 10/14/2014 Provider Tool Effective Date: 12/12/2015 Request is for Noninvasive EBGS for individual with failed spinal fusion (If checked, mark all of the following that apply): A minimum of 6 months has passed since date of the original surgery Serial x-rays or appropriate imaging studies show no progression of healing for 3 months during the latter portion of the 6 month period Other: Request is for Noninvasive EBGS for fracture nonunion of long or short bones of the appendicular skeleton Request is for Noninvasive EBGS for congenital pseudoarthroses of long or short bones of the appendicular skeleton: (If checked, mark all of the following that apply) At least 45 days have passed since date of fracture At least 45 days have passed since the date of surgical treatment of fracture Serial radiographs or appropriate imaging studies confirm no progressive signs of healing have occurred Fracture gap is less than one centimeter Other: Request is for Noninvasive EBGS for treatment of joint fusion secondary to failed arthrodesis of the knee Request is for Noninvasive EBGS for treatment of joint fusion secondary to failed arthrodesis of the ankle Request is for Invasive electrical bone growth stimulation (EBGS) for any non-spinal indication Request is for the Semi-Invasive electrical bone growth stimulation (EBGS) for an indication not specified Please specify the indication: ___________________ Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of synovial pseudoarthroses Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of draining osteomyelitis Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of fresh fractures Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of delayed/incomplete union fractures Request is for the Noninvasive electrical bone growth stimulation (EBGS) as an adjunct (that is, at the time of or immediately after) to a bunionectomy procedure Request is for the Noninvasive electrical bone growth stimulation (EBGS) as an adjunct (that is, at the time of or immediately after) to distraction osteogenesis procedures for any indication (for example, limb lengthening, nonunion or tibial defects) Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of patellar tendinopathy Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of pathological fractures due to bone pathology Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of pathological fractures due to tumor/malignancy Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of spondylolysis Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of pars interarticularis defect Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of stress fractures Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of any other condition: Specify condition: Page 2 of 3 REVIEW REQUEST FOR Electrical Bone Growth Stimulation Provider Data Collection Tool Based on Medical Policy DME.00004 Policy Last Review Date: 08/14/2014 Policy Effective Date: 10/14/2014 Provider Tool Effective Date: 12/12/2015 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 Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Page 3 of 3