Cardiac Resynchronization Therapy

REVIEW REQUEST FOR Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Provider Data Collection Tool Based on Medical Policies 2.02.10; SURG.00064 Policy Last Review Date: 4/2010; 02/25/2010 Policy Effective Date: 04/2010; 04/21/2010 Provider Tool Effective Date: 02/15/2011

Individual’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 Service Requested (CPT if known): Outpatient Other: Diagnosis (ICD-9) if known):

Please check all that apply to the individual:

Request is for FDA-approved biventricular pacemaker for cardiac resynchronization therapy (CRT) Request is for a FDA-approved ICD, in combination with cardiac resynchronization therapy (CRT/ICD) (*** If checked, you must complete and submit this document as well as the Clinical Data Submission Tool - SURG.00033 Implantable Cardioverter-Defibrillator (ICD) ***)

Individual has NYHA functional Class III or ambulatory Class IV symptoms, secondary to heart failure who remain symptomatic despite recommended, optimal medical therapy Individual has cardiac dyssynchrony, (which is currently defined as a QRS duration greater than 120 ms) Individual’s left ventricular ejection fraction (LVEF) less than or equal to 35% Individual is in sinus rhythm. Other (Please list):

*** MUST BE COMPLETED*** Please classify the individual according to the New York Heart Association (NYHA) definitions: CLASS I – Individual with cardiac disease but without resulting limitation of physical activity; ordinary physical activity does not cause undue fatigue, palpitation , dyspnea, or anginal pain; symptoms only occur on severe exertion

of 2 REVIEW REQUEST FOR Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Provider Data Collection Tool Based on Medical Policies 2.02.10; SURG.00064 Policy Last Review Date: 4/2010; 02/25/2010 Policy Effective Date: 04/2010; 04/21/2010 Provider Tool Effective Date: 02/15/2011

CLASS II – Individual has cardiac disease resulting in slight limitation of physical activity; they are comfortable at rest; ordinary physical activity (e.g., moderate physical exertion, such as carrying shopping bags up several flights of stairs) result in fatigue, palpitation, dyspnea, or anginal pain. CLASS III – Individual has cardiac disease resulting in marked limitation of physical activity; they are comfortable at rest; less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain. CLASS IV – Individual has cardiac disease resulting in the inability to carry on any physical activity without discomfort; symptoms of heart failure or the anginal syndrome may be present even at rest; if any physical activity is undertaken, discomfort is increased.

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