REVIEW REQUEST FOR
Endothelial Keratoplasty
Provider Data Collection Tool Based on Medical Policies 9.03.21; SURG.00108
Policy Last Review Date: 08/2010; 02/25/2010 / Policy Effective Date: 08/2010; 04/21/2010 / Provider Tool Effective Date: 03/02/2011Individual’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: Home Inpatient
Outpatient Other:
Service Requested (CPT if known):
Diagnosis (ICD-9) if known):
Please check all that apply to the individual:
Request is for Descemet's stripping endothelial keratoplasty (DSEK) for treatment of disorders of the corneal endothelium.
Request is for Descemet's stripping endothelial keratoplasty (DSEK) for treatment of disease or injury of the corneal stroma (e.g. keratoconus, corneal ulcers caused by infection and traumatic corneal injuries)
Request is for Descemet's stripping automated endothelial keratoplasty (DSAEK) for treatment of disorders of the corneal endothelium
Request is for Descemet's stripping automated endothelial keratoplasty (DSAEK) for treatment of disease or injury of the cornea stroma (e.g. keratoconus, corneal ulcers caused by infection and traumatic corneal injuries)
Individual has Fuchs' endothelial dystrophy
Individual has Aphakic & pseudophakic bullous keratopathy (corneal edema following cataract extraction)
Individual has had a failure or rejection of a previous corneal transplant
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
Page 2 of 2
REVIEW REQUEST FOR
Endothelial Keratoplasty
Provider Data Collection Tool Based on Medical Policies 9.03.21; SURG.00108
Policy Last Review Date: 08/2010; 02/25/2010 / Policy Effective Date: 08/2010; 04/21/2010 / Provider Tool Effective Date: 03/02/2011Page 2 of 2
REVIEW REQUEST FOR
Endothelial Keratoplasty
Provider Data Collection Tool Based on Medical Policies 9.03.21; SURG.00108
Policy Last Review Date: 08/2010; 02/25/2010 / Policy Effective Date: 08/2010; 04/21/2010 / Provider Tool Effective Date: 03/02/2011Page 2 of 2