Please Check All That Apply to the Individual

REVIEW REQUEST FOR Septoplasty Provider Data Collection Tool Based on Clinical Guideline CG-SURG-18 Policy Last Review Date: 05/05/2016 Policy Effective Date: 06/28/2016 Provider Tool Effective Date: 10/14/2016

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 Code(s) (if known):

This clinical guideline based data collection tool is for a medical necessity review request for a septoplasty procedure. This document may also be used to review the septoplasty component of a rhinoseptoplasty. Septoplasty is a surgical procedure performed to correct airway obstruction related to the nasal septum. These obstructions can be caused by structural deformity, disease or trauma. Medically necessary criteria for the rhinoplasty component of the combined procedure and relevant coding instructions can be found in ANC.00008 Cosmetic and Reconstructive

Please check all that apply to the individual:

□ Request is for a Nasal Septoplasty procedure (If checked, mark all of the following that apply to the individual) □ Individual has completed an appropriate and reasonable trial of conservative management (topical nasal corticosteroids, decongestants, antibiotics, allergy evaluation and therapy, etc.) □ The trial of conservative management has failed □ Individual has symptomatic septal deviation or deformity (If checked, mark all of the following that apply to the individual) □ Individual has distressing symptoms of nasal obstruction with documentation of the absence of other causes of obstruction responsible for the symptoms (for example, nasal polyps, tumor, etc) □ Individual has persistent epistaxis □ Individual has recurrent epistaxis □ Individual has chronic recurrent sinusitis REVIEW REQUEST FOR Septoplasty Provider Data Collection Tool Based on Clinical Guideline CG-SURG-18 Policy Last Review Date: 05/05/2016 Policy Effective Date: 06/28/2016 Provider Tool Effective Date: 10/14/2016

□ The individual has an asymptomatic deformity that prevents surgical access to other intranasal or paranasal areas (for example, sinuses, turbinates) (If checked, mark the following if it applies to the individual) □ Surgical access to intranasal areas or sinuses is required

□ The procedure is for the treatment of snoring, in the absence of other symptoms or conditions

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 the health plan or its designees may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.

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Name and Title of Provider or Provider Representative Completing Date Form and Attestation (Please Print)*

*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted.

Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan.