REVIEW REQUEST FOR
Functional Endoscopic Sinus Surgery
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-24
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/08/2013
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:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Other:
Diagnosis Code(s) (if known):
Please check all that apply to the individual:
Functional Endoscopic Sinus Surgery
Request is for Functional endoscopic sinus surgery for: (check all that apply)
Sinusitis
Polyposis
Sinus tumor
Other (please describe):
Individual has the following conditions: (check all that apply):
Individual has suspected tumor seen on: (check all that apply)
Imaging
Physical examination
Endoscopy
Individual has suppurative (pus forming) complications: (check all that apply)
Subperiosteal abscess
Brain abscess
Other (please describe)
Individual has chronic polyposis
Symptoms are unresponsive to medical therapy
Individual has allergic fungal sinusitis as indicated by: (check all that apply)
Nasal polyposis
Positive CT findings
Eosinophilic mucus
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Inpatient
REVIEW REQUEST FOR
Functional Endoscopic Sinus Surgery
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-24
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/08/2013
Individual has a mucocele causing chronic sinusitis
Individual has recurrent sinusitis that: (check all that apply)
Triggers pulmonary disease (e.g. asthma, cystic fibrosis)
Aggravates pulmonary disease (e.g. asthma, cystic fibrosis)
Individual has uncomplicated sinusitis (for example., sinusitis confined to the paranasal sinuses without adjacent
involvement of neurologic, soft tissue or bony structures) and: (check all that apply)
Four or more documented episodes of acute rhinosinusits (for example, less than 4 weeks in duration) in
one year
Chronic sinusitis (for example., greater than 12 weeks in duration) that interferes with lifestyle
Maximal medical therapy has been attempted as indicated by: (check all that apply)
Antibiotic therapy for at least 4 weeks
Trial of inhaled steroids
Nasal lavage
Allergy testing (if symptoms are consistent with allergic rhinitis and have not responded to
appropriate environmental controls and pharmacotherapy (antihistamines, intranasal
corticosteroids, leukotriene antagonists, etc.)
Individual has abnormal findings from diagnostic work-up as indicated by: (check all that apply)
CT findings suggestive of obstruction or infection for example,but not limited to, air fluid levels,
air bubbles, significant mucosal thickening, pansinusitis, or diffuse opacification
Nasal endoscopy findings suggestive of significant disease
Physical exam findings suggestive of chronic/recurrent disease (ie: mucopurulence, erythema,
edema, inflammation)
Individual has a fungal mycetoma
Individual has failed some other sinus surgery
Individual has cerebrospinal fluid rhinorrhea
Individual has an encephalocele
Individual has posterior epistaxis (relative indication)
Individual has persistent facial pain after other causes are ruled out (relative indication)
Individual has a cavernous sinus thrombosis caused by chronic sinusitis
Other (please describe):
Other (please describe):
Nasal or Sinus Cavity Debridement Following FESS
Request is for nasal or sinus cavity debridement following FESS: (check all that apply)
Up to two times during the first 30 days postoperatively
Postoperative loss of vision or double vision
Evidence of cerebrospinal fluid leak such as rhinorrhea
Prompted by symptoms of nasal obstruction related to:
Nasal polyps unresponsive to oral or nasal steroids
Documented presence of papilloma, carcinoma or other neoplasm
Allergic fungal sinusitis
Other (please describe):
Other (please describe):
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REVIEW REQUEST FOR
Functional Endoscopic Sinus Surgery
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-24
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/08/2013
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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