REVIEW REQUEST FOR

MultipleSleep Latency Testing (MSLT)

and Maintenance of Wakefulness Testing (MWT)

Provider Data Collection Tool Based on Clinical Guideline CG-MED-43

Policy Last Review Date: 02/05/2015 / Policy Effective Date: 04/07/2015 / Provider Tool Effective Date: 04/15/14
Individual’s Name: / Date of Birth:
Insurance Identification Number/HCID: / 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:
Date/Date Range of Service: / Place of Service: Home Inpatient
Outpatient Other:
Service Requested (CPT/HCPCS if known):
Diagnosis Code(s) ( if known):

Please check all of the following that apply to the individual:

Test(s) requested (check all that apply)

Request is for Multiple Sleep Latency Testing (MSLT)

Request is for Portable Multiple Sleep Latency Testing in home setting

Request is for Maintenance of Wakefulness Testing

Test is for any of the following conditions (check all that apply):

Evaluation of narcolepsy or Suspected Idiopathic Hypersomnia when the individual being evaluated has

excessive daytime sleepiness or disrupted nocturnal sleep of greater than 8 weeks duration (Please check all that

apply):

Symptoms of narcolepsy, such as cataplexy, sleep paralysis, hypnagogic hallucinations (occur just

before sleep), or hypnopompic hallucinations (occur just before waking) are present

Obstructive Sleep Apnea (OSA) has been ruled out by polysomnography

OSA has been diagnosed but symptoms persist despite adequate treatment with Positive Airway

Pressure Therapy

Other:

For routine diagnosis of Obstructive Sleep Apnea

Follow up after treatment of sleep related disorders

Evaluation of sleepiness in medical or neurological disorders (other than narcolepsy or idiopathic hypersomnia), including but not limited to, insomnia, circadian rhythm disorders and Shift Work Sleep disorder (SWSD)

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 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 CompletingDate

Form and Attestation (Please Print)*

*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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