Gastric Electrical Stimulation

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Gastric Electrical Stimulation
REVIEW REQUEST FOR
Gastric Electrical Stimulation
Provider Data Collection Tool Based on Medical Policy SURG.00046
Policy Last Review Date: 02/25/2010
Policy Effective Date: 04/21/2010
Provider Tool Effective Date: 03/09/2011
Member Name:
Date of Birth:
Insurance Identification Number:
Member 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 (ICD-9) if known):
Please check all that apply to the member:
Request is for Gastric electrical stimulation to treat
Chronic intractable nausea and vomiting (Check all that apply)
Secondary to severe gastroparesis diabetic etiology
Secondary to severe gastroparesis idiopathic etiology
Other: (please describe)
Obesity
Other: (please describe)
Member has the following (check all that apply)
Member is refractory, intolerant or has contraindications to the use of prokinetic medications
Member is refractory, intolerant or has contraindications to the use of antiemetic medications
Member has delayed gastric emptying as documented by standard scintigraphic imaging of solid food
Other: (please describe)
This request is being submitted:
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REVIEW REQUEST FOR
Gastric Electrical Stimulation
Provider Data Collection Tool Based on Medical Policy SURG.00046
Policy Last Review Date: 02/25/2010
Policy Effective Date: 04/21/2010
Provider Tool Effective Date: 03/09/2011
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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