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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Medical-Surgical Clinical Data Submissions Tools

PW_B138549
 
A Pre-certification or Predetermination Tool is used by the provider to submit clinical information for an authorization request (precert or predetermination). If a provider uses this tool, chart records and letters of medical necessity will not be needed unless the tool is selected for auditing.  
The Clinical Data Submission Tools on this site may be used to submit clinical information for either a pre-service review (pre-certification or pre-determination) or Post Service review, including pre or post claim submission.  
 
The patient's demographic information should be completed in the first section of the tool.
The patient's clinical information should be completed in the second section of the tool by checking the series of boxes all that applies to the patient's medical condition.
After completion of the Clinical Data Submission Tools-, the information should be submitted to the Utilization Management address or fax number referenced in this contact list. If you would like to submit the tool via e-mail, please contact the Utilization Management Department to obtain the appropriate address to submit the tool. If you are not set up for secure E-Review and would like to be, please contact the Utilization Management Department.
The information, when filled out completely, should provide Utilization Management the necessary clinical information, including condition and history, to determine if the case meets the medical necessity criteria.
In some select situations, you may be asked to submit medical records (such as random auditing), or additional information such as photographs or visual fields, as an example.
Please make sure that physician or physician representative signs and checks the attestation at the bottom of the Clinical Data Submission Tool before submitting for review.
 
Ancillary
Cosmetic Reconstructive Services: Skin Related ANC.0007
Cosmetic and Reconstructive Services of the Trunk and Groin ANC.00009
 
Durable Medical Equipment
Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) CG-DME-07
Hospital Beds and Accessories CG-DME-15
Electrical Bone Growth Stimulator DME.00004
Home Oxygen Therapy CG-DME-18 Provider tool
Lower Limb Prosthesis CG-DME-13 Provider tool
Myoelectric Upper Extremity Prosthetic Devices CG-OR-PR-05
Oscillatory Devices for Airway Clearance including High Frequency Chest Compression (Vest Airway Clearance System) and Intrapulmonary Percussive Ventilation (IPV) DME.00012
Prothrombin Time Self-monitoring Devices CG-DME-30
Spinal Orthoses Thoracic-Lumbar Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar CG-DME-11
Wheeled Mobility Devices: Manual Wheelchairs – Standard, Heavy Duty, and Lightweight CG-DME-24
Wheeled Mobility Devices: Wheelchairs–Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) CG-DME-31
Ultrasound Bone Growth Stimulation DME.00027
Ultraviolet Light Therapy Delivery Devices for Home Use DME.00036
Vacuum Assisted Wound Therapy in the Outpatient Setting DME.00009
Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight CG-DME-33
External (Portable) Continuous Insulin Infusion Pump CG-DME-01
 
Genetics
Cardiac Ion Channel Genetic Testing GENE.00007
Diagnostic Genetic Testing of a Potentially Affected Individual (Adult or Child) GENE.00013
Gene Expression Profiling for Managing Breast Cancer Treatment GENE-00011
Genetic Testing for Colorectal Cancer Susceptibility - GENE.00028
Genetic Testing for Breast and_or Ovarian Cancer Syndrome - GENE.00029
Genetic Testing for Endocrine Gland Cancer Susceptibility - GENE.00030
Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status GENE.00010
Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent GENE.00012
 
Laboratory
None.  
 
Medicine
Central Bone Density Measurement & Screening for Vertebral Fractures CG-MED-39 Provider Tool
Multiple Sleep Latency Testing and other Sleep Testing Services CG-MED-00043
Diaphragmatic/Phrenic Nerve Stimulation MED.00100
Hyperbaric Oxygen Therapy MED.00005
Iontophosresis for Medical Indications CG-MED-28
Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer CG-MED-38
Manipulation Under Anesthesia of the Spine and Joints other than the Knee MED.00079
Treatment of Hyperhidrosis MED.00032
Wearable Cardioverter Defibrillators MED.00055
 
Orthotics-Prosthetics
Microprocessor Controlled Lower Limb Prostheses OR-PR.00003
Prefabricated and Prophylactic Knee Braces CG-OR-PR-02
Custom Made Knee Braces CG-OR-PR-03
 
Radiology
Brachytherapy for Oncologic Indications RAD.00014
Intensity Modulated Radiation Therapy RAD.00041
Intraoperative Radiation Therapy RAD.00017
Neutron Beam Radiotherapy RAD.00047
Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy RAD.00031
Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors RAD.00011
Wireless Capsule Endoscopy for Esophogeal & Small Bowel Imaging & the Patency Capsule RAD.00030
 
Rehabilitation
None. 
 
Surgery
Maze Procedure CG-SURG-05
Septoplasty CG-SURG-18
Autologus, Allogenic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting SURG.00011
Blepharoplasty, Blepharoptosis Repair, and Brow Lift CG-SURG-03
Bone Anchored Hearing Aids SURG.00020
Breast Procedures including Reconstructive Surgery, Implants and Other Breast Procedures SURG.00023
Cardiac Resynchronization Therapy with or without an Implantable Cardioverter (CRT/ICD) for Treatment of Heart Failure SURG.00064
Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement SURG.00001
Cochlear and Auditory Brainstem Implants SURG.00014
Cryosurgical Ablation of Tumors outside the liver SURG.00025
Deep Brain Stimulation SURG.00026
Endothelial Keratoplasty SURG.00108
Endovascular/Endoluminal Repair of Aortic Aneurysms, Aorticiliac Disease, Aortic Dissection and Aortic Transection SURG.00054
Fetal Surgery for Prenatally Diagnosed Malformations SURG.00036
Functional Endoscopic Sinus Surgery CG-SURG-24
Gastric Electrical Stimulation SURG.00046
Hysterectomy
Implantable Cardioverter Defibrillator (ICD) SURG.00033
Implanted Spinal Cord Stimulators SURG.00060
Implantable Infusion Pumps SURG.00068
Intraocular Anterior Segment Aqueous Drainage Devices SURG.00103
Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies SURG.00065
Mandibular/Maxillary (Orthognathic) Surgery SURG.00049
Mastectomy for Gynecomastia SURG.00085
Oral, Pharyngeal and Maxillofacial Surgery for Treatment of Obstructive Sleep Apnea SURG.000129
Panniculectomy, Abdominoplasty SURG.00048
Penile Prosthesis Implantation_CG-SURG-12_Provider Tool
Percutaneous Neurolysis for Chronic Back Pain SURG.00066
Percutaneous Spinal Procedures (Vertebroplasty, Kyphoplasty and Sacroplasty) SURG.00067
Ablative Techniques as a Treatment for Barrett's Esophagus SURG.00106
Radiofrequency and Pulsed Radiofrequency Neurolysis for Trigeminal Neuralgia (TGN) SURG.00090
Radiofrequency Ablation to Treat Tumors Outside the Liver SURG.00050
Reduction Mammaplasty SURG.00086
Refractive Surgery SURG.00009
Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury CG-SURG-08
Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention SURG.00117
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT) SURG.00017
Surgery for Clinically Severe Obesity SURG.00024
Temporomandibular Disorders CG-SURG-09
Tonsillectomy for Children CG-SURG-30
Total Ankle Replacement SURG.00081
Transcatheter Uterine Artery Embolization CG-SURG-28 Provider Tool
Treatments for Urinary Incontinence SURG.00010
Treatment of Osteochondral Defects SURG.00093
Transcatheter Closure of Patent Foramen Ovale and Left Artial Appendage for Stroke Prevention SURG.00032
Transcatheter Heart Valves SURG.00121
Treatment of Varicose Veins SURG.00037
Vagus Nerve Stimulation Therapy SURG.00007
 
Transplant
None.  
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