Cosmetic Reconstructive Services Skin Related
REVIEW REQUEST FOR
Cosmetic & Reconstructive Services: Skin Related
Provider Data Collection Tool Based on Medical Policy ANC.00007
Policy Last Review Date: 02/26/09 Policy Effective Date: 02/26/09
Member Name:
Provider Tool Effective Date: 10/01/09
Date of Birth:
Insurance Identification Number: Member Phone Number:
Provider ID Number: Ordering Provider Name & Specialty:
Office Address:
Office Phone Number:
Rendering Provider Name & Specialty:
Office Fax Number:
Provider ID Number:
Office Address:
Office Phone Number: Office Fax Number:
Facility Name:
Facility Address:
Date/Date Range of Service:
Service Requested (CPT if known):
Facility ID Number:
Place of Service: Home Inpatient
Outpatient Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the member:
Request is for any of the following:
Treatment of Telangiectasias
Temporary or permanent renmoval of hair for hirsutism
Hairplasty for male pattern alopecia
Removal or excision of a tattoo.
Request is for Chemical peel—[epidermal peels or chemotherapy of the skin] (Please complete below):
Member has active acne
To treat photo-aged skin, wrinkles, acne scarring or uneven epidermal pigmentation
Other:
Request is for medium or deep Chemical peel—[dermal peel] (Please complete below):
Documented evidence of 10 or more actinic keratoses or other pre-malignant lesions
Member has failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy
To treat photo-aged skin, wrinkles, acne, acne scarring or uneven epidermal pigmentation
Other:
Request is for Collagen Injections or Implants (Please complete below):
Documented physical functional impairment & the treatment can be reasonably expected to improve the
physical function impairment.
Need for restoration and there is significant variation from the normal related to accidental injury, trauma,
treatment of disease, or congenital defect.
(Please describe): ______________________________
Other:
Request is for Dermabrasion or Salabrasion (Please complete below):
Documented evidence of the removal of 10 or more superficial basal cell carcinomas and precancerous actinic
keratoses
Member has failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy
For abrasion of the upper layer of the skin for acne, acne scars, uneven pigmentation or wrinkles
Other:
Request is for laser and surgical treatment of Acne Rosacea (Please complete below):
The member has severe and refractory form of Rosacea unresponsive to standard medical therapy.
The member has had an adequate trial of topical or oral agents or both (antibiotics).
There is documentation that the individual has undergone and received inadequate results with conservative
management
Preoperative photos document the clinical skin changes requiring treatment *** Please attach photo’s.
Other:
Request is to treat permanent telangiectasia (Please complete below):
Using electrosurgery
Using laser (pulsed dye V-beam, the 585 flash pump laser, KTPlaser)
Using intense pulsed light (IPL) therapy
Other:
Request is to treat severe rhinophyma (Please complete below):
Using radiofrequency cutting current and a hockey puck adapter
Using carbon dioxide laser peel
Using surgical shaving
Other:
Request is for treatment of keloids (Please complete below):
Documented physical functional impairment related to the keloid & the treatment can be reasonably expected to
improve the physical function impairment.
Keloids themselves produce significant anatomic variance
Other:
Request is for Scar Revision (Please complete below):
There is documentation of physical functional impairment related to the scar the treatment can be reasonably
expected to improve the physical function impairment.
Need for restoration and there is significant variation from the normal related to accidental injury, disease,
trauma, treatment of disease, or congenital defect.
(Please describe): ______________________________
Other:
Request is for Tattooing of the skin (Please complete below):
Done as part of a medically necessary therapeutic process (ie, radiation therapy, or as a result of reconstructive
Breast surgery.
Other:
Request is for the injection of dermal fillers, such as poly-L-lactic acid (Sculptra), and a synthetic calcium
hydroxylapatitie (Radiesse) when used to address a significant variation from normal (Please complete below):
Realted to accidental injury
Related to disease or trauma
For the treatment of a disease or congenital defect
Other:
Request is for the treatment of port wine stain with laser or other methods (Please complete below):
To restore appearance when used to address a significant variation from the normal related to a congenital defect
Other:
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Other:
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
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In
Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In
Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc.
(RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community
Insurance Company. In Virginia (excluding the City of Fairfax, the Town of Vienna and the area east of State Route 123 Anthem Blue Cross and
Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliated HMOs,
HealthKeepers, Inc., Peninsula Health Care, Inc. and Priority Health Care, Inc. are independent licensees of the Blue Cross and Blue Shield
Association. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies;
Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and
BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ®
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue
Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. For some plans utilization review services are provided by Anthem UM Services, Inc., a separate company.
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