REVIEW REQUEST FOR
Intraocular Anterior Segment Aqueous Drainage
Devices (without extraocular reservoir)
Provider Data Collection Tool Based on Medical Policy SURG.00103
Policy Last Review Date: 08/14/2014
Policy Effective Date:
01/01/2015
Provider Tool Effective Date: 10/14/2014
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:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
Please check all that apply to the individual:
Request is for :
Ex-PRESS™ Glaucoma Filtration Device
Anterior segment aqueous drainage device, inserted internally or externally without an extraocular reservoir
iStent Trabecular Micro-bypass Stent
Other (please list)
Check all that apply to the individual:
Individual has refractory open- angle glaucoma (primary and secondary)
Medication therapies have failed to control intraocular pressure
Other (please list)
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REVIEW REQUEST FOR
Intraocular Anterior Segment Aqueous Drainage
Devices (without extraocular reservoir)
Provider Data Collection Tool Based on Medical Policy SURG.00103
Policy Last Review Date: 08/14/2014
Policy Effective Date:
01/01/2015
Provider Tool Effective Date: 10/14/2014
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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