REVIEW REQUEST FOR
Ophthalmologic Techniques for Evaluating Glaucoma
Provider Data Collection Tool Based on Medical Policy MED.00006 FOR POST SERVICE CLAIM REVIEW FOR
DATES OF SERVICE BEFORE 08/21/2011 ONLY
Policy Last Review Date: 11/18/2010
Policy Retired: 08/22/2011
Provider Tool Effective Date: 03/22/2012
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:
Service Requested (CPT if known):
Place of Service:
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.
Page 1 of 2
REVIEW REQUEST FOR
Ophthalmologic Techniques for Evaluating Glaucoma
Provider Data Collection Tool Based on Medical Policy MED.00006 FOR POST SERVICE CLAIM REVIEW FOR
DATES OF SERVICE BEFORE 08/21/2011 ONLY
Policy Last Review Date: 11/18/2010
Policy Retired: 08/22/2011
Provider Tool Effective Date: 03/22/2012
_____________________________________________________________
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
Page 2 of 2