REVIEW REQUEST FOR
Microprocessor Controlled Lower Limb Prosthesis
Provider Data Collection Tool Based on Medical Policy 1.01.25; OR-PR.00003
Policy Last Review Date: 02/2010; 02/25/2010 / Policy Effective Date: 02/2010; 04/21/2010 / Provider Tool Effective Date: 03/15/2011Member 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: Home Inpatient
Outpatient Other:
Service Requested (CPT if known):
Diagnosis (ICD-9) if known):
Please check all that apply to the member:
Request is for microprocessor controlled prosthesis: (Check all that apply)
Otto-Bock C-Leg device®
Ossur RheoKnee®
Endolite Intelligent Prosthesis®
Propio Foot®
Other (Please List):
Individual hastransfemoral (above knee) amputation
Individual has knee disarticulation amputation
Other (Please List):
Individual has an adequate cardiovascular reserve and cognitive learning ability to master the higher level technology and to allow for faster than normal walking speed
Individual hasdemonstrated the ability to ambulate faster than their baseline rate using a standard prosthetic application with a swing and stance control knee
Documented need for daily long distance ambulation (i.e., greater than 400 yards) at variable rates
Need is limited to use within the home or for basic community ambulation
Demonstrated need for regular ambulation on uneven terrain or regular use on stairs
Need is limited to stair climbing in the home or place of employment
Undergone complete multidisciplinary assessment including an evaluation by a trained prosthetic clinician****
**** The complete multidisciplinary assessment must also accompany this document. Please attach.****
Other (Please List):
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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REVIEW REQUEST FOR
Microprocessor Controlled Lower Limb Prosthesis
Provider Data Collection Tool Based on Medical Policy 1.01.25; OR-PR.00003
Policy Last Review Date: 02/2010; 02/25/2010 / Policy Effective Date: 02/2010; 04/21/2010 / Provider Tool Effective Date: 03/15/2011Page 1 of 2