REVIEW REQUEST FOR
Carotid, Vertebral and Intracranial Artery
Stent Placement with or without Angioplasty
Provider Data Collection Tool Based on Medical Policy Surg.00001
Policy Last Review Date: 02/05/2015
Policy Effective Date: 04/07/2015
Provider Tool Effective Date: 04/15/2014
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:
EXTRACRANIAL STENT PLACEMENT WITH OR WITHOUT ANGIOPLASTY
Request is for
Extracranial carotid artery stent placement with angioplasty
Extracranial carotid artery stent placement without angioplasty
Other (please list):
Check all that apply to the individual:
Individual can be safely treated by this approach
Individual has angiographically visible intraluminal thrombus
Individual has no angiographically visible intraluminal thrombus
Individual has: (Check all that apply)
Symptomatic stenosis equal to or greater than 50%
Asymptomatic stenosis equal to or greater than 80%
Complete occlusion (100% stenosis) of the relevant carotid artery
Symptomatic stenosis less than 50% of the relevant carotid artery
Asymptomatic stenosis less than 80% of the relevant carotid artery
Contralateral laryngeal nerve palsy
Existence of lesions distal or proximal to the carotid bulb and bifurcation of the common carotid
Radiation-induced stenosis following previous radiation therapy to the neck or radical neck dissection
Restenosis after carotid endarterectomy (CEA)
Severe tandem lesions that may require endovascular therapy
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REVIEW REQUEST FOR
Carotid, Vertebral and Intracranial Artery
Stent Placement with or without Angioplasty
Provider Data Collection Tool Based on Medical Policy Surg.00001
Policy Last Review Date: 02/05/2015
Policy Effective Date: 04/07/2015
Provider Tool Effective Date: 04/15/2014
Stenosis secondary to arterial dissection
Stenosis secondary to fibromuscular dysplasia
Stenosis secondary to Takayasu arteritis
Stenosis that is surgically difficult to access (for example, high bifurcation requiring mandibular dislocation)
Stenosis associated with contralateral carotid artery occlusion
Stenosis that cannot be safely reached or crossed by endovascular approach
Pseudoaneurysm
Inability to move the neck to a suitable position for surgery
Tracheostomy
Stenosis or aneurysm of extracranial vertebral arteries or intracranial arteries
Other (please list):
Individual is at high risk for surgery (check all that apply)
Individual has Congestive heart failure (NYHA Class III/IV)
Left ventricular ejection fraction less than 30%
Open heart surgery needed within the next 6 weeks
History of recent myocardial infarction (greater than 24 hours and less than 4 weeks)
Individual has severe chronic obstructive pulmonary disease
Individual has unstable angina (CCS class III/IV)
Other (please list):
INTRACRANIAL STENT WITH OR WITHOUT ANGIOPLASTY
Request is for percutaneous intracranial artery stent placement with or without angioplasty as part of the treatment of
individuals with an intracranial aneurysm.
Surgical treatment is not appropriate or attempted surgery was unsuccessful
Standard endovascular techniques (coiling) are inadequate to achieve complete isolation of the aneurysm
because of anatomic considerations which include (please check all that apply)
Wide-neck aneurysm (4 mm or more)
Sack-to-neck ratio less than 2:1
Other (please list):
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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