REVIEW REQUEST FOR
Stretching Devices for the Treatment of
Joint Stiffness and Contracture
Provider Data Collection Tool Based on Medical Policy DME.00028
Policy Last Review Date: 11/18/2010 / Policy Effective Date: 01/01/2011 / Provider Tool Effective Date: 03/21/2011Individual’sName: / Date of Birth:
Insurance Identification Number: / Individual’sPhone 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:(Check all that apply)
Dynamic low-load prolonged-duration stretch (LLPS) device for the knee, elbow, wrist or finger
Bi-directional static progressive (SP) stretch device for the knee, elbow, wrist or finger
Patient-actuated serial stretch (PASS) device for the knee, elbow, wrist or finger
Device requested to treat chronic joint stiffness or chronic or fixed contractures
Other (Please list):
Choose from the following settings:
Subacute injury or post-operative period (3 or more weeks but not more than 4 months after injury or operation)
(Check all that apply)
In addition to physical therapy for individual with signs and symptoms of persistent joint stiffness or contracture
Individual has limited range of motion judged by the physician to be a meaningful functional limitation and has not
responded to other therapy (including physical therapy)
For an initial period of up to 4 months
For continuation of treatment after initial period and significant improvement can be demonstrated.
If checked, please describe the progress:
Other (Please list):
Acute post-operative period
Individual has undergone additional surgery to improve the range of motion of a previously affected joint
For an initial period of up to 4 months
For continuation of treatment after initial period and significant improvement can be demonstrated.
If checked, please describe the progress:
Other (Please list):
Individual is unable to benefit from standard physical therapy modalities because of an inability to exercise
For an initial period of up to 4 months
For continuation of treatment after initial period and significant improvement can be demonstrated.
If checked, please describe the progress:
Other (Please list):
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 1 of 2
REVIEW REQUEST FOR
Stretching Devices for the Treatment of
Joint Stiffness and Contracture
Provider Data Collection Tool Based on Medical Policy DME.00028
Policy Last Review Date: 11/18/2010 / Policy Effective Date: 01/01/2011 / Provider Tool Effective Date: 03/21/2011Page 1 of 2
REVIEW REQUEST FOR
Stretching Devices for the Treatment of
Joint Stiffness and Contracture
Provider Data Collection Tool Based on Medical Policy DME.00028
Policy Last Review Date: 11/18/2010 / Policy Effective Date: 01/01/2011 / Provider Tool Effective Date: 03/21/2011Page 1 of 2