REVIEW REQUEST FOR
Cosmetic & Reconstructive Services: Skin Related
Provider Data Collection Tool Based on Medical Policy ANC.00007
Policy Last Review Date: 08/06/2015
Policy Effective Date:
10/06/2015
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
10/06/2015
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:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
Please Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this
document. Benefit language supersedes this document.
Please refer to this definition of *‘Significant physical functional impairment’ in the completion of this request:
Limits on normal physical functioning that may include, but are not limited to, problems with communication, respiration,
eating, swallowing, visual impairments, skin integrity, distortion of nearby body parts, or obstruction of an orifice. The cause
of the physical functional impairment may be pain, structural integrity, congenital anomalies or other factors. Significant
physical functional impairment excludes social, emotional, and psychological impairments or potential impairments
Please check all that apply to the individual:
A.
Chemical Peels
Request is for chemical peel (known as epidermal peels or chemotherapy of the skin)
(If checked, please identify the treatment indication below)
Active acne
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.
Request is for a dermal peal (a medium or deep chemical peel) for the treatment of 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
Other:
B. Collagen Injections
Request is for collagen injections or implants (If check, please mark the following that apply)
There is documented evidence of *significant physical functional impairment and the procedure can be
reasonably expected to improve the physical function impairment.
Treatment is reconstructive and intended to address a significant variation from the normal related to accidental
injury, disease, trauma, treatment of disease, or a congenital defect
(Please describe the variation and contributing factor):
Treatment will be performed in the absence of a *significant physical functional impairment, is not
reconstructive and is intended to change a physical appearance that would be considered within normal human
anatomic variation
Other:
C. Cutaneous Hemangioma, Port Wine Stain, and other Vascular Lesions
Request is for treatment of cutaneous hemangioma, port wine stain, or other vascular lesions using lasers or other
methods to address functional impairment and/or restore appearance
There is documented evidence of *significant physical functional impairment (for example, bleeding or a lesion
which interferes with vision) and the procedure can reasonably be expected to improve the physical functional
impairment.
Treatment is reconstructive and intended to address a congenital defect that has created a significant
variation from normal
Treatment will be performed in the absence of a *significant physical functional impairment, is not reconstructive,
and is intended to change a physical appearance that would be considered within normal human anatomic
variation.
D. Dermabrasion
Request is for dermabrasion (abrasion or salabrasion) (If checked, identify the treatment indication 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:
E. Hair Procedures
Request is for permanent hair removal. (If checked please identify the treatment indication below)
Recurrent infected cyst
Hair follicle infections
After surgical treatment of pilonidal sinus disease
Other:
Request is for hairplasty for alopecia, including male pattern alopecia
Request is for temporary or permanent hair removal using electrolysis, lasers, or waxing in the absence of a
*significant physical functional impairment and is intended to change a physical appearance that would be
considered within normal human anatomic variation (for example, the removal of unwanted hair due to hirsutism)
Other:
F. Injection of Dermal Fillers
Request is for the injection of dermal fillers, such as poly-L-lactic acid (PLLA), or synthetic calcium
hydroxylapatite (If checked, please complete the following that apply)
Treatment is intended to address a significant variation from the normal related to accidental injury, disease,
trauma, treatment of disease, or a congenital defect
(Please describe the variation and contributing factor(s)):
Other:
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G. Laser and Surgical Treatment of Rosacea and Telangiectasis
Request is for laser or surgical treatment of severe rosacea (If checked, please mark all
of the following that apply)
Individual’s rosacea is refractory and unresponsive to standard medical therapy.
Preoperative photos document the clinical skin changes requiring treatment.
*** Please attach clinical photos to this request.
Request is for laser or surgical treatment of isolated rosacea or telangiectasia (including spider veins) in the absence
of a *significant physical functional impairment and are intended to change a physical appearance that would be
considered within normal human anatomic variation.
Other:
H. Other Cosmetic Skin Procedures
Request is for laser skin resurfacing. (If checked, please identify the treatment indication below)
Facial wrinkles
Skin irregularities (for example, acne scars or blemishes)
Other:
I.
Tattoos (Application)
Request is for tattooing of the skin (If checked, please mark the following that apply)
Individual requires tattooing 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:
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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