REVIEW REQUEST FOR
Refractive Surgery
Provider Data Collection Tool Based on Medical Policy SURG.00009
Policy Last Review Date: 05/15/2014
Policy Effective Date: 07/15/2014
Provider Tool Effective Date: 09/29/2010
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 (ICD-9) if known):
Please check all that apply to the individual:
CORNEAL RELAXING INCISION / CORNEAL WEDGE RESECTION
Request is for correction of surgically induced astigmatism with a corneal relaxing incision or corneal wedge resection
The astigmatism is the result of a previous cataract surgery, medically necessary refractive surgery, scleral buckling for
retinal detachment, or corneal transplant
The degree of astigmatism is 3.00 diopters or greater
The medical records document inadequate functional vision with contact lenses, spectacles or both.
Others (Please list):
LASIK, LASEK, PRK, or PARK/PRK-A
Request is for: (Check all that apply)
Laser in situ keratomileusis (LASIK)
Laser epithelial keratomileusis (LASEK)
Photorefractive keratectomy (PRK)
Photoastigmatic keratectomy (PARK or PRK-A)
Prior cataract, corneal, or scleral buckling surgery for retinal detachment has been performed on this eye.
Medical record documents that symptoms are due to aniseikonia (different sizes of ocular images) or anisometropia
(difference in power of refraction)
The medical records document inadequate functional vision with contact lenses, spectacles or both.
Post-operative spherical equivalent refractive error has changed by 3 diopters when compared to the preoperative refractive
error or the degree of astigmatism is 3 diopters or greater
Other (Please list):
EPIKERATOPLASTY (EPIKERATOPHAKIA)
Request is for epikeratoplasty (epikeratophakia)
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REVIEW REQUEST FOR
Refractive Surgery
Provider Data Collection Tool Based on Medical Policy SURG.00009
Policy Last Review Date: 05/15/2014
Policy Effective Date: 07/15/2014
Provider Tool Effective Date: 09/29/2010
For correction of refractive errors of acquired or congenital aphakia
For hypermetropia following cataract surgery and the individual is unable to receive intraocular lens
Other (Please list):
IMPLANTATION OF INTRASTROMAL CORNEAL RING SEGMENTS
Request is for the implantation of intrastromal corneal ring segments (i.e., INTACS™) for individual with keratoconus
For progressive deterioration in vision, such that the individual can no longer achieve adequate functional vision on a daily
basis with either contact lenses or spectacles
Individual is 21 years of age or older
There is the presence of a clear central cornea
The corneal thickness is 450 microns or greater at the proposed incision site
Individual has corneal transplantation as the only remaining option to improve their functional vision.
For correction of myopia
Other (Please list):
OTHER
Laser thermal keratoplasty (LTK)
Radial keratotomy and its variants
Implantable contact lenses without lens extraction (phakic intraocular lenses)
Clear lens extraction (CLE) with or without implantation of an accommodating or nonaccommodating lens
Conductive keratoplasty to treat presbyopia
Keratophakia
Orthokeratology
Standard keratomileusis
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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