REVIEW REQUEST FOR
Locally Ablative Techniques for Treating
Primary and Metastatic Liver Malignancies
Provider Data Collection Tool Based on Anthem Medical Policy SURG.00065
Policy Last Review Date: 05/13/2010
Policy Effective Date: 07/07/2010
Provider Tool Effective Date: 05/26/2010
Inddividual’s Name:
Date of Birth:
Insurance Identification Number:
Inddividual’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
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the individual:
I. SURGICAL EXCISION
Request is for surgical excision of primary hepatobiliary carcinoma (check all that apply):
Hepatocellular carcinoma
Cholangiocarcinoma
Other:
Request is for surgical excision of liver metastases from (check all that apply):
Colorectal cancer
Functioning neuroendocrine tumors
Other solid tumors
Other:
Please complete the following member selection criteria (check all that apply):
Complete excision of the carcinoma is anticipated
Two contiguous hepatic segments will be preserved
At least 20% of the total estimated liver volume will be preserved
Adequate biliary drainage will be preserved
Vascular inflow will be preserved
Vascular outflow will be preserved
Extrahepatic disease is present and has been or will be resected
Request is for a repeat procedure
Six months have elapsed since prior procedure (surgical resection or ablation)
Other:
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Inpatient
REVIEW REQUEST FOR
Locally Ablative Techniques for Treating
Primary and Metastatic Liver Malignancies
Provider Data Collection Tool Based on Anthem Medical Policy SURG.00065
Policy Last Review Date: 05/13/2010
Policy Effective Date: 07/07/2010
Provider Tool Effective Date: 05/26/2010
Individual has 3 or less lesions
Lesion(s) have been documented by CT scan or MRI
Each lesion is no more than 5 cm in diameter
Other:
II. OTHER LOCAL ABLATIVE TECHNIQUES
Request is for other local ablative techniques (check all that apply):
Percutaneous ethanol injection
Radiofrequency,
Cryosurgical ablation
Microwave ablation
Other:
Please complete the following individual selection criteria (check all that apply):
Individual has hepatocellular carcinoma
Individual has liver metastasis from colorectal cancer
Individual has liver metastasis from neuroendocrine tumors
Individual is poor candidate for or unwilling to undergo surgical resection
Individual has 3 or less lesions
Lesion(s) have been documented by CT scan or MRI
Each lesion is no more than 5 cm in diameter
Individual is free of extrahepatic disease
All foci of disease are amenable to ablative therapy
Request is for a repeat procedure
Six months have elapsed since prior procedure (surgical resection or ablation)
Other:
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 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
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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