REVIEW REQUEST FOR
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-30
Policy Last Review Date: 11/13/2014 Policy Effective Date: 01/13/2015
Individual’s Name:
Insurance Identification Number:
Provider Tool Effective Date: 01/13/2015
Date of Birth:
Individual’s Phone Number:
Provider ID Number: Ordering Provider Name & Specialty:
Office Address:
Office Phone Number: Office Fax Number:
Rendering Provider Name & Specialty:
Office Address:
Office Phone Number:
Provider ID Number:
Office Fax Number:
Facility Name:
Facility Address:
Date/Date Range of Service:
Service Requested (CPT if known):
Facility ID Number:
Place of Service: Home Inpatient
Outpatient Other:
Diagnosis Code(s) ( if known):
Please check all that apply to the individual:
Request is for tonsillectomy for an individual less than 18.0 years of age
Individual has history of recurrent throat infection with a frequency of: (check all that apply)
7 episodes in the past year
5 episodes per year for 2 years
3 episodes per year for 3 years
There is documentation in the medical record for each episode of sore throat which includes the following symptoms:
(check all that apply)
Temperature greater than 38.3°C (100.9 °F)
Cervical adenopathy
Tonsillar exudates or erythema
Positive test for Group A β-hemolytic streptococcus (GABHS)
Other (please list):
Individual has history of recurrent throat infections with additional factors that favor tonsillectomy: (check all that apply)
Multiple antibiotic allergy/intolerance
Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome
Peritonsillar abscess
Parapharyngeal abscess
Other (please list):
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REVIEW REQUEST FOR
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-30
Policy Last Review Date: 11/13/2014 Policy Effective Date: 01/13/2015 Provider Tool Effective Date: 01/13/2015
Individual has a diagnosis of sleep-disordered breathing (SDB*) with documentation of: (check all that apply)
Tonsillar hypertrophy
Abnormalities of respiratory pattern or the adequacy of ventilation during sleep, including but not limited to snoring, mouth breathing and pauses in breathing*
A condition related to SDB (including but not limited to growth retardation, poor school performance, enuresis, and behavioral problems) that is likely to improve after tonsillectomy
Other (please list):
*Documentation of SDB can be made on the basis of physical and history only, and does not require polysomnography. A history of snoring alone is not sufficient to make a diagnosis of SDB
Individual is a child less than 3 years of age and has a diagnosis of SDB with documentation of: (check all that apply)
Tonsillar hypertrophy
SDB is chronic (more than 3 months in duration)
Child’s parent or caregiver reports regular episodes of nocturnal choking, gasping, apnea or breath holding
Other (please list):
Individual has a diagnosis of obstructive sleep apnea (OSA) with documentation of: (check all that apply)
Tonsillar hypertrophy
A polysomnogram with an Apnea-Hypopnea Index (AHI) greater than 1.0
Other (please list):
There is suspicion of tonsillar malignancy
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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