REVIEW REQUEST FOR
Ophthalmologic Techniques for Evaluating Glaucoma
Provider Data Collection Tool Based on Medical Policy MED.00006
Policy Last Review Date: 11/18/2010
Policy Effective Date: 01/12/2011
Provider Tool Effective Date: 07/14/2010
Member Name:
Date of Birth:
Insurance Identification Number:
Member 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:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the member:
Request is for testing for routine glaucoma screening
Request is for testing for diagnosis of indidvuals with suspected glaucoma
Request is for testing of individuals with established glaucoma
Examination Planned: (check all that apply)
Retinal nerve fiber layer analysis for the evaluation of the appearance of the optic nerve with scanning laser
tomography/confocal scanning laser tomography/scanning laser ophthalmoscopy (e.g. Heidelberg retinal tomography
(Heidelberg Engineering, Dossenheim, Germany)
Scanning laser polarimetry with:Nerve Fiber Analyzer GDx™ (Carl Zeiss Meditec, Inc, Dublin CA)
Optical coherence tomography of the posterior segment with Stratus OCT™ (Carl Zeiss Meditec, Inc, Dublin CA)
Pachymetry to measure central corneal thickness as an adjunct evaluation tool
Initial evaluation with pachymetry
Repeat (confirmatory test) evaluation with pachymetry
Other: (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 Anthem may perform a
routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
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REVIEW REQUEST FOR
Ophthalmologic Techniques for Evaluating Glaucoma
Provider Data Collection Tool Based on Medical Policy MED.00006
Policy Last Review Date: 11/18/2010
Policy Effective Date: 01/12/2011
Provider Tool Effective Date: 07/14/2010
_____________________________________________________________
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. For some plans utilization review services are provided
by Anthem UM Services, Inc., a separate company.
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