REVIEW REQUEST FOR
Manipulation Under Anesthesia of the Spine and
Joints other than the Knee
Provider Data Collection Tool Based on Medical Policy MED.00079
Policy Last Review Date: 05/07/2015
Policy Effective Date: 07/07/2015
Provider Tool Effective Date: 10/27/2010
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):
Home
Outpatient
Inpatient
Other:
Diagnosis Code(s) (if known):
Please check all that apply to the individual:
Request is for manipulation under anesthesia (MUA) of the shoulder for treatment of adhesive capsulitis (frozen shoulder)
Request is for spinal manipulation under anesthesia (SMUA). (Check any that apply)
Treatment of vertebral fracture
Treatment of complete dislocation
Treatment of acute traumatic incomplete dislocation (subluxation)
Other (please list): ____________
Request is for manipulation under anesthesia of joint other than the knee, shoulder or spine
Other (please list): ____________
Other (please list): ____________
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REVIEW REQUEST FOR
Manipulation Under Anesthesia of the Spine and
Joints other than the Knee
Provider Data Collection Tool Based on Medical Policy MED.00079
Policy Last Review Date: 05/07/2015
Policy Effective Date: 07/07/2015
Provider Tool Effective Date: 10/27/2010
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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