Please Check All That Apply to the Member

REVIEW REQUEST FOR

Implantable Infusion Pumps

Provider Data Collection Tool Based on Coverage Guideline SURG.00068

Policy Last Review Date: 02/25/10 / Policy Effective Date: 04/21/10 / Provider Tool Effective Date: 8/10/09
Member Name: / Date of Birth:
Insurance Identification Number/HCID: / 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:
Date/Date Range of Service: / Place of Service: Home Inpatient
Outpatient Other:
Service Requested (CPT/HCPCS if known):
Diagnosis (ICD-9) if known):

Please check all that apply to the member:

Request is for an implantable infusion pump to deliver drugs for the treatment of specific conditions

Request is for a permanently implanted intrathecal infusion pump for the administration of opiates or non-opiate analgesics for the treatment of

Chronic intractable malignant pain

Chronic intractable non-malignant pain

Request is for a temporary trial of intrathecal infusion pump for the administration of opiates or non-opiate analgesics for

the treatment of

Chronic intractable malignant pain

Chronic intractable non-malignant pain

Request is for infusion of heparin for thromboembolic disease

Request is for infusion of antibiotics for osteomyelitis

Request is for a fully implantable insulin pump

Other:

Member has the following conditions: (check all that apply)

Primary liver cancer (intrahepatic artery injection of chemotherapeutic agents)

Metastatic colorectal cancer where metastases are limited to the liver (intrahepatic artery injection of chemotherapeutic

agents)

Head/neck cancers (Intra-arterial injection of chemotherapeutic agents)

Severe, refractory spasticity of cerebral or spinal cord origin in member who is unresponsive to or who cannot tolerate oral

baclofen (Lioresal®) therapy (intrathecal injection of baclofen)

Strong opioids or other analgesics in adequate doses, with fixed schedule (not PRN) dosing have failed to relieve pain or

intolerable side effects to systemic opioids or other analgesics have developed

Life expectancy is greater than 3 months

Tumor encroachment on the thecal sac has been ruled out by appropriate testing

No contraindications to implantation exist such as sepsis or coagulopathy

A temporary trial of spinal (epidural or intrathecal) opiates or non-opiate analgesics has been successful prior to permanent

implantation as defined by a 50% reduction in pain

There is documentation in the medical records of improved function as a result of a temporary trial of an intrathecal infusion pump

Pain has a duration of greater than 6 months

Documentation of the failure of 6 months of other conservative treatment modalities (pharmacologic, surgical,

psychologic, or physical) , if appropriate and not contraindicated

Intractable pain secondary to a disease state with objective documentation of pathology in the medical record

Further surgical intervention is not indicated

Psychological evaluation has been obtained and evaluation unequivocally states that the pain is not psychologic in origin

and that benefit would occur with implantation

Other:

This request is being submitted:

Pre-Claim

Post–Claim. If checked, please attach the claim or indicate the claim number

By checking this box, 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 of Provider or Provider Representative Completing Form* 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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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the City of Fairfax, the Town of Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), whichunderwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"),which underwritesor administers the HMO policies; and Compcare and BCBSWicollectively, which underwriteor administer thePOS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association and BCBSWicollectively, which underwriteor administer thePOS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. For some plans utilization review services are provided by Anthem UM Services, Inc., a separate company.

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