REVIEW REQUEST FOR
Fetal Surgery for Prenatally Diagnosed
Malformations
Provider Data Collection Tool Based on Medical Policy SURG.00036
Policy Last Review Date: 02/13/2014
Policy Effective Date: 04/15/2014
Provider Tool Effective Date: 04/13/2011
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):
Please check all that apply to the individual:
Request is for fetal surgery for vesico-amniotic shunting as a treatment of urinary tract obstruction: (Check all that apply)
Fetus has a bilateral obstruction
There is evidence of progressive oligohydramnios
Fetus has adequate renal function reserves
There are no other lethal or chromosomal abnormalities
Other (Please list):
Request is for either open or in-utero resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt as
a treatment of either congenital cystic adenomatoid malformation or extralobar pulmonary sequestration (Check all that apply)
Fetus is at 32 weeks gestation or less with evidence of fetal hydrops, placentamegaly , or the beginnings of severe
pre-eclampsia (i.e., the maternal mirror syndrome) in the mother
Other (Please list):
Request is for in-utero removal of sacrococcygeal teratoma: (Check all that apply)
Fetus is at 32 weeks gestation or less with evidence of fetal hydrops, placentamegaly , or the beginnings of severe
pre-eclampsia (i.e., the maternal mirror syndrome) in the mother
Other (Please list):
Request is for fetal surgery for the repair of myelomeningocele: (Check all that apply)
Singelton pregnancy
Myelomeningocele with the upper boundary of the lesion located between T1 and S1
Evidence of hindbrain herniation
Gestational age of 19.0 to 25.9 weeks
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REVIEW REQUEST FOR
Fetal Surgery for Prenatally Diagnosed
Malformations
Provider Data Collection Tool Based on Medical Policy SURG.00036
Policy Last Review Date: 02/13/2014
Policy Effective Date: 04/15/2014
Provider Tool Effective Date: 04/13/2011
Normal fetal karyotype
Are any of the following contraindications to in utero repair of myelomingocele present?
Fetal anomaly unrelated to the myelomeningocele
Severe fetal kyphosis
Short cervix (less than or equal to 15 mm
Previous pre-term birth
Placental abruption
Maternal Body Mass Index (BMI) greater than or equal to 35
Contraindications to surgery, including but not limited to previous hysterotomy in the active (upper) uterine
segment
Other (Please list):
Request is for fetal surgery to induce temporary tracheal occlusion as a treatment of congenital diaphragmatic hernia (CDH)
Request is for fetal surgery to treat aqueductal stenosis
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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