REVIEW REQUEST FOR
Vagus Nerve Stimulation
Provider Data Collection Tool Based on Anthem Medical Policy SURG.00007
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/14/2014
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):
This form is for service requests for implantable vagus nerve (VNS) devices, the electronic analysis of the
implanted neurostimulator pulse generator system, and non-implantable (transcutaneous) VNS devices for
the treatment of medically and surgically refractory seizures associated with intractable epilepsy and as a
treatment of other conditions.
Please check all that apply to the individual:
Request is for the implantation of a vagus nerve stimulation device
Request is for a non-implantable (transcutaneous) vagus nerve stimulation device
Request is for an electronic analysis of an implanted neurostimulator pulse generator system for vagus nerve stimulation
Individual has medically and surgically refractory seizures
Individual has failed more than one trial of single or combination anti-epileptic medications, as evidenced by:
persistent seizures
intolerable side effects of drug therapy
Individual has failed or is not a candidate for resective epilepsy surgery
Request is to treat individual for these following conditions: (if checked, please complete below)
Alzheimer's disease
Anxiety and mood disorders
Autism
Bipolar disorders
Bulimia
Cerebral palsy
Depression
Essential tremors
Fibromyalgia
Headaches (including cluster and migraine headaches)
Heart failure
Obesity
Seizures (that do not meet the medically necessary criteria)
Sleep disorders
Other: (please describe):
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REVIEW REQUEST FOR
Vagus Nerve Stimulation
Provider Data Collection Tool Based on Anthem Medical Policy SURG.00007
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/14/2014
Other request not listed above: (please describe):
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 it’s
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 Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance
Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies,
Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. For some plans utilization review services are
provided by Anthem UM Services, Inc., a separate company.
.
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