REVIEW REQUEST FOR Ultrasound Bone Growth Stimulation Provider Data Collection Tool Based on Medical Policy DME.00027 Policy Last Review Date: 08/06/2015 Policy Effective Date: 10/06/2015 Provider Tool Effective Date: 12/12/2015 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 Inpatient Other: Diagnosis Code(s) (if known): This medical policy based data collection tool is for medical necessity review for the use of lowintensity pulsed ultrasound devices as a treatment to promote healing of some fresh fractures and to accelerate healing for nonunion of other fracture sites. Read carefully and make your selection appropriately. You MUST accurately complete this form specific to your request to facilitate your review request. Please check all that apply to the individual: Request is for non-invasive, low-intensity pulsed ultrasound treatment for fresh fracture * *NOTE: FRESH FRACTURE (a term for a fracture that has recently occurred, typically considered equal to or less than seven days in duration, and has not had previous treatment, other than emergency splinting prior to evaluation and fixation) (If checked, mark all of the following that apply to the individual) Individual has a closed radial fracture, posteriorly displaced (Colles') Individual has a closed tibial diaphyseal fracture Individual has a Grade I open tibial diaphyseal fracture Individual has a closed fracture site at high risk for nonunion due to location and poor vascular supply (for example, carpal navicular/scaphoid fractures, Jones/5th metatarsal fracture) Individual has a closed fracture site at high risk for nonunion due to associated extensive soft tissue or vascular damage REVIEW REQUEST FOR Ultrasound Bone Growth Stimulation Provider Data Collection Tool Based on Medical Policy DME.00027 Policy Last Review Date: 08/14/2014 Policy Effective Date: 10/14/2014 Provider Tool Effective Date: 12/12/2015 Individual has a closed fracture at high risk for nonunion due to a comorbidity: (If checked, mark all of the following that apply to the individual) Diabetes where bone healing is likely to be compromised Renal disease where bone healing is likely to be compromised A metabolic diseases where bone healing is likely to be compromised History of tobacco use History of alcoholism Nutritional deficiency The individual is obese with a Body Mass Index (BMI) greater than 30 The individual is obese and is greater than 50% over their ideal body weight (IBW) Severe anemia Steroid therapy Other: ________________ Request is for non-invasive, low-intensity pulsed ultrasound treatment for fracture nonunion ** of the appendicular skeleton (clavicle, humerus, radius, ulna, femur, fibula, tibia, carpal, metacarpal, tarsal, or metatarsal) **NOTE: FRACTURE NONUNIONS (a fracture in which all evidence of bone growth activity at the fracture site has ceased, leaving a persistent unhealed fracture of the bone) (If checked, mark all of the following that apply to the individual) At least 45 days have passed since the date of fracture At least 45 days have passed since the date of appropriate fracture care Serial radiographs or appropriate imaging studies confirm there is no evidence of progression of healing The fracture gap is less than one centimeter Request is for non-invasive, low-intensity pulsed ultrasound treatment as an adjunct (at the time of or immediately after) to a bunionectomy procedure Request is for non-invasive, low-intensity pulsed ultrasound treatment as an adjunct (at the time of or immediately after) to distraction osteogenesis procedures for any indication (for example, limb lengthening, nonunion or tibial defects) Request is for non-invasive, low-intensity pulsed ultrasound treatment of axial skeleton fractures, including the skull and vertebrae Request is for non-invasive, low-intensity pulsed ultrasound treatment of congenital pseudoarthrosis Request is for non-invasive, low-intensity pulsed ultrasound treatment for delayed fracture union Request is for non-invasive, low-intensity pulsed ultrasound treatment for open Grade II fresh fractures Request is for non-invasive, low-intensity pulsed ultrasound treatment for open Grade III fresh fractures Request is for non-invasive, low-intensity pulsed ultrasound treatment for fresh fractures that require surgical intervention (with or without internal fixation) Request is for non-invasive, low-intensity pulsed ultrasound treatment for fresh fractures that are too unstable for closed reduction /casting Request is for non-invasive, low-intensity pulsed ultrasound treatment for patellar tendinopathy Request is for non-invasive, low-intensity pulsed ultrasound treatment for pathological fractures due to bone pathology Request is for non-invasive, low-intensity pulsed ultrasound treatment pathological fractures due to tumor/malignancy Request is for non-invasive, low-intensity pulsed ultrasound treatment for stress fractures Page 2 of 3 REVIEW REQUEST FOR Ultrasound Bone Growth Stimulation Provider Data Collection Tool Based on Medical Policy DME.00027 Policy Last Review Date: 08/14/2014 Policy Effective Date: 10/14/2014 Provider Tool Effective Date: 12/12/2015 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. Page 3 of 3