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: 05/07/2015 Policy Effective Date: 07/07/2015
Individual’s Name:
Insurance Identification Number:
Provider Tool Effective Date: 07/07/2015
Date of Birth:
Individual’s Phone Number:
Provider ID Number: Ordering Provider Name & Specialty:
Office Address:
Office Phone Number:
Rendering Provider Name & Specialty:
Office Address:
Office Phone Number:
Office Fax Number:
Provider ID Number:
Office Fax Number:
Facility Name:
Facility Address:
Date/Date Range of Service:
Service Requested (CPT if known):
Diagnosis Code(s) (if known):
Facility ID Number:
Place of Service: Home Inpatient
Outpatient Other:
Please check all that apply to the individual:
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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: 05/07/2015 Policy Effective Date: 07/07/2015 Provider Tool Effective Date: 07/07/2015
I. SURGICAL EXCISION* (See NOTE at top of tool)
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 individual 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 is anticipated to 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:
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* (See NOTE at top of tool)
Request is for other local ablative techniques (check all that apply):
Percutaneous ethanol injection (PEI)
Radiofrequency ablation (RFA)
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 functioning 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:
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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: 05/07/2015 Policy Effective Date: 07/07/2015 Provider Tool Effective Date: 07/07/2015
III. BRIDGE TO LIVER TRANSPLANT
Request is for the following as a bridge to liver transplantation (check all that apply):
Percutaneous ethanol injection (PEI)
Radiofrequency ablation (RFA)
Microwave ablation
Other:
Please complete the following individual selection criteria (check all that apply):
Preserved liver function defined as Childs-Turcotte-Pugh Class A or B
Three or fewer encapsulated nodules and
No evidence of extra-hepatic metastases each nodule is less than or equal to 5 centimeters in diameter
No evidence of severe renal function impairment
No evidence of portal vein occlusion
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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