REVIEW REQUEST FOR
Transcatheter Arterial Chemoembolization (TACE)
and Transcatheter Arterial Embolization(TAE) for
Treating Primary or Metastatic Liver Tumors
Provider Data Collection Tool Based on Medical Policies 8.01.11;RAD.00011
Policy Last Review Date: 10/2010; 11/18/2010 / Policy Effective Date: 10/2010; 01/12/2011 / Provider Tool Effective Date: 03/16/2011Individual’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:
Please choose which procedure you are requesting and then proceed / complete the disease specific criteria listed below.
Request is for Transcatheter arterial chemoembolization (TACE)
Request is for Transcatheter arterial embolization (TAE)
Request is for TACE utilizing chemotherapy-loaded microspheres (i.e. drug-loaded microspheres, drug-eluting beads)
Other:
Primary Hepatic Malignancy or Metastatic Tumors of the Liver
Request is for treatment of liver-only metastasis from uveal (ocular) melanoma
Request is for palliative treatment for an individual with neuroendocrine tumor(s) (carcinoid tumors, pancreatic islet cell tumors, parathyroid, pituitary angiomas) with hepatic metastases when systemic therapy has failed to control symptoms such as carcinoid syndrome (debilitating flushing, wheezing, and diarrhea)
Request is for palliative treatment for an individualwith symptoms from non-carcinoid neuroendocrine tumors with hepatic metastasis (hypoglycemia, severe diabetes, Zollinger-Ellison Syndrome)
Request is for palliative treatment for an individualwithspecific liver related symptoms due to tumor bulk(e.g., pain) from any primary or metastatic hepatic tumor
Other:
Hepatocellular Carcinoma or Bridge to Liver Transplanantion
Request is for treatment of HepatocellularCarcinoma or Bridge to Liver Transplantation (if checked, please complete below)
Primary treatment for a surgically unresectable primary hepatocellular carcinoma
Treatment is for bridge to liver transplantation
Individual has preserved liver function defined as Childs-Turcotte-Pugh Class A or B
Individual has 3 or fewer encapsulated nodules and nodules are less than 5 cm in diameter
Individual has no evidence of extra-hepatic metastases
Individual has no evidence of severe renal function impairment
Individual has no evidence of portal vein occlusion
Other:
Hepatocellular Carcinoma in Individuals Who May Become Eligible for Liver Transplantation
Request is for treatment of an individual who may become eligible for liver transplantation except that the hepatic lesion(s) exceed(s) five centimeters in maximal diameter
It can be reasonably expected that treatment with TACE or TAE will result in tumor size reduction to less than five centimeters in maximal diameter
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 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
Transcatheter Arterial Chemoembolization (TACE)
and Transcatheter Arterial Embolization(TAE) for
Treating Primary or Metastatic Liver Tumors
Provider Data Collection Tool Based on Medical Policies 8.01.11;RAD.00011
Policy Last Review Date: 10/2010; 11/18/2010 / Policy Effective Date: 10/2010; 01/12/2011 / Provider Tool Effective Date: 03/16/2011Page 1 of 2