REVIEW REQUEST FOR
Cochlear & Auditory Brainstem Implants
Provider Data Collection Tool Based on Medical Policy SURG.00014
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 07/15/2014
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):
Please check all that apply to the individual:
Cochlear Implants
Request is for an FDA-approved single channel cochlear implant
Request is for an FDA-approved multi-channel cochlear implant
Request is for hybrid cochlear implantation
The cochlear implantation will be unilateral
The cochlear implantation will be bilateral
Other: (please describe)
Initial Request:
Individual has bilateral severe to profound pre- or postlingual hearing loss (sensorineural deafness) defined as a hearing
threshold of 70 decibels (dB) or greater.
Individual has obtained limited benefit from conventional hearing aids
Individual is free from lesions in the auditory nerve and acoustic areas of the central auditory pathway (nervous system)
Individual is free from otitis media or other active middle ear infections
Individual is able to participate in a post-cochlear implant rehabilitation program
Other: (please describe)
Upgrade/Replacement request: **Please mark type of implant above**
Request is for upgrade to or replacement of an existing external speech processor, controller or speech processor
and controller (integrated system)
Upgrade/replacement is for convenience
Upgrade/replacement is to upgrade to a newer technology when the current components remain functional.
Individual’s response to existing component is inadequate to the point of interfering with activities of daily living
Components of current device are no longer functional.
Other: (please describe)
Auditory Brain Stem Implants
Request is for an FDA-approved auditory brainstem implant (ABI)
Other: (please describe)
Initial Request:
Individual is 12 years of age or older
Individual is diagnosed with Neurofibromatosis Type II
Individual is completely deaf as a result of bilateral neurofibromas of the auditory nerve
Other: (please describe)
Upgrade/Replacement Request: **Please mark type of implant above**
Request is for upgrade to or replacement of an existing external sound processor, remote assistant or both components
(Please check 1 of the following reasons for Upgrade/Replacement request)
Upgrade/replacement is for convenience
Upgrade/replacement is to upgrade to a newer technology when the current components remain functional.
Individual’s response to existing component is inadequate to the point of interfering with activities of daily living
Components of current device are no longer functional.
Other: (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 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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