REVIEW REQUEST FOR
Continuous Passive Motion Devices
Provider Data Collection Tool Based on Medical Policies 1.01.10 DME.00019
Policy Last Review Date: 07/2010; 08/19/2010
Policy Effective Date: 07/2010; 10/13/2010
Provider Tool Effective Date: 02/15/2011
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:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the individual:
Request is for Continuous Passive Motion (CPM) device applied within 72 hours following surgery
Request is for CPM use for longer than 21 days from date of first application
Other: (please list)
Individual is status post anterior cruciate ligament (ACL) repair
Individual is status post articular osteochondral repair procedures of the knee (such as microfracture, osteochondral
grafting, autologous chondrocyte implantation (ACI), meniscal allograft, treatment of osteochondritis dissecans, repair of
tibial plateau fractures
Individual is status post posterior cruciate ligament (PCL) repair
Individual is status post total knee arthroplasty (TKA) or TKA revision
Request is subsequent to arthroplasty or the release of an arthrofibrosis of the elbow or knee, shoulder, wrist or hand. (e.g.
elbow arthroplasty, rotator cuff repair or arthroplasty or metacarpal joint phalangeal arthroplasty)
Request is for any of the following (check all that apply):
Treatment of ankle or toe conditions
Treatment of chronic contractures
Treatment of degenerative joint diseases
Treatment of distal radial fractures
Treatment of idiopathic club foot in infants
Treatment of stroke with hemiparesis
Treatment of TMJ (temporomandibular joint)
Other (explain):
Device was initially applied in an inpatient setting prior discharge
Date of surgery
Date of device application
Discharge date
Other uses: (please list)
Codes:
Procedure Code(s): ________________________
Diagnosis Code(s): ________________________
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 Anthem 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
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