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Spinal Surgery Precertification Information Request Form

PCFX . Spinal Surgery Precertification Information Request Form. Applies to: Aetna plans . Innovation Health® plans Health benefits and health insurance plans offered, underwritten and/or

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  Health, Information, Innovation, Surgery, Aetna, Precertification, Spinal, Spinal surgery precertification information, Innovation health

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Text of Spinal Surgery Precertification Information Request Form

Page 1 of 5 PCFX Spinal SurgeryPrecertification Information Request FormApplies to: Aetna plans Innovation Health plans Health benefits and health insurance plans offered and/or underwritten by the following: Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner|Aetna) Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance Company (Texas Health Aetna) Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services on behalf of its affiliates. GR-68893-2 (1-18)Page 2 of 5 GR-68893-2 (1-18)About this form You can t use this form to initiate a precertification request. To initiate a request, you have to call our Precertification Department. Or you can submit your request electronically. Failure to complete this form and submit all of the medical records we are requesting may result in the delay of review. Effective January 11, 2018, this form replaces all other Spinal Surgery precertification information request documents and forms. This form will help you supply the right information with your precertification request. You don t have to use the form. But it will help us adjudicate your request more quickly. How to fill out this form As the patient s attending physician, you must complete all sections of the form. You can use this form with all Aetna health plans, including Aetna s Medicare Advantage plans. You can also use this form with health plans for which Aetna provides certain management services. When you re doneOnce you ve filled out the form, submit it and all requested medical documentation to our Precertification can send it via confidential fax to: Precertification Commercial Plans: 859-455-8650 Precertification-Medicare Advantage Standard Organization Determination: 859-455-8650 Precertification-Medicare Advantage (expedited only): 860-754-5468Or you can mail it to: PO Box 14079 Lexington, KY 40512-4079What happens next? Once we receive the requested documentation, we ll perform a clinical review. Then we ll make a coverage determination and let you know our decision. Your administrative reference number will be on the electronic precertification response. How we make coverage determinations If you request spinal surgery precertification for an Aetna Medicare Advantage member, we use Centers for Medicare & Medicaid Services benefit policies when available to make a coverage determination. These benefit policies include National Coverage Determinations (NCD) and Local Coverage Determinations (LCD). If no NCD or LCD is available, we ll use the Aetna Clinical Policy Bulletins (CPB) referenced below to make the coverage determination. For all other members, we encourage you to review CPB #16: Back Pain Invasive Procedures, CPB #411: Bone and Tendon Graft Substitutes, CPB #591: Intervertebral Disc Prostheses and CPB #743: Spinal Surgery: Laminectomy and Fusion before you complete this form. You can find the Clinical Policy Bulletins and Precertification Lists by visiting the website on the back of the member s ID card. Questions? If you have any questions about how to fill out the form or our precertification process, call us at: HMO plans: 1-800-624-0756 Traditional plans: 1-888-632-3862PCFXSpinal SurgeryPrecertification Information Request Form Page 3 of 5 GR-68893-2 (1-18) Spinal SurgeryPrecertification Information Request FormSection 1: To be completed by the Precertification Department Member name: Administrative reference number (required): Member ID: Member date of birth: Requesting provider/facility name: Requesting provider/facility NPI: Requesting provider/facility phone number: 1- - Requesting provider/facility fax number: 1- - Referring physician name: Referring physician phone number: 1- - - Referring physician phone number: 1- - Section 2: Provide the following information for all cervical, thoracic or lumbar requests Procedure: Provide a detailed description. Refer to CPB #743. Levels of surgery: CPT codes requested: Does this procedure require an endoscopic approach? Yes No Will a C-arm be used for this procedure? Yes No Select the planned procedure, if applicable: Anterior cervical disc fusion (ACDF) ACDF with corpectomy Anterior lumbar interbody fusion (ALIF) with posterior instrumentation ALIF and posterolateral fusion ALIF with anterior instrumentation Direct lateral interbody fusion (DLIF) Extreme lateral interbody fusion (XLIF) Interlaminar lumbar instrumented fusion (ILIF) MAST Multiple level scoliosis correction surgery Oblique Lateral Interbody Fusion (OLIF) Posterior lumbar interbody fusion (PLIF) PLIF/TLIF and posterolateral fusion Posterolateral fusion with posterior instrumentation Transformational lumbar interbody fusion (TLIF) Section 3: Provide the following information for assistant/co-surgeon, if applicable Assistant/co-surgeon name and TIN: CPT codes requested: - - - Page 4 of 5 GR-68893-2 (1-18) Spinal Surgery Precertification Information Request Form Section 4: Provide the following information for prosthetic intervertebral discs, instrumentation and bone grafts Prosthetic intervertebral discs ( , Bryan Cervical Disc, MOBI-C , Prestige Cervical Disc , ProDisc -C or L Total Disc Replacement, Secure-C Artificial Cervical Disc, Charit TM artificial disc, NuBacTM, DASCOR Disc Arthroplasty System). Refer to CPB # 591. CPT code: Manufacturer: Device name:Example: 22856, ProDisc-C Total Disc ReplacementBone grafts (allografts): Provide a detailed description, including the manufacturer and name of implant. Refer to CPB # CPT codes 20930 and 20931 ( , Accell , AlloFuse , Allogor DBM, Allomatrix , DBX , DynaGraft , Exactech Resorbable Bone Paste, Grafton DBM, OsteoSelect , OsteoSponge , or cadaver). CPT code: Manufacturer: Device name: Example: 20930, AlloFuse allograft Instrumentation: Provide a detailed description, including the manufacturer and name of implant. Refer to CPB #16. Includes cages, spacers, rods, pedicle screws and plates for CPT codes 22840-22847 and 22853-22859 ( , Medtronic Capstone PEEK Spinal System, AccelSPINE Cezanne II, DePuy Synthes VIPER Cortical Fix Screw, DePuy Synthes Zero-P zero-profile anterior cervical interbody fusion device, Globus Medical Coalition spacer). For example: 22854, Stryker AVS Anchor-C interbody fusion device with internal screw fixation Anterior instrumentation CPT code: Manufacturer: Device name:Posterior instrumentation CPT code: Manufacturer: Device name:Cage/Spacer CPT code: Manufacturer: Device name:Does the cage contain plates and screws? Yes No Note: Include intervertebral body fixation devices or cages, interspinous or interlaminar distraction devices, interspinous fixation devices and dynamic stabilization. Page 5 of 5 Spinal Surgery Precertification Information Request Form Section 5: Provide the following documentation for your request Medical records related to the member s condition for which treatment is proposed, including the following: Documentation of all clinical findings Detailed neurological/orthopedic examination Conservative therapy, including type, duration and outcome Physical therapy notes, including duration and outcome Current plan of care All radiological and imaging reports (myelogram, CT, MRI, spinal X-rays) Section 6: Read this important information Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal andcivil penalties. Section 7: Sign the form Just remember: You can t use this form to initiate a precertification request. To initiate a request, you have to call our Precertification Department. Or you can submit your request of treating doctor or other qualified healthcare provider:Date:/ / Contact name of office personnel to call with questions: Telephone number: 1- GR-68893-2 (1-18) - -

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