<p>REVIEW REQUEST FOR Cochlear & Auditory Brainstem Implants Provider Data Collection Tool Based on Medical Policies 7.01.05; SURG.00014 Policy Last Review Date: 03/2010; 11/18/10 Policy Effective Date: 03/2010; 11/18/10 Provider Tool Effective Date: 02/15/2011</p><p>Individual’s Name: Date of Birth: Insurance Identification Number: Individual’s Phone Number: </p><p>Ordering Provider Name & Specialty: Provider ID Number: Office Address: Office Phone Number: Office Fax Number: </p><p>Rendering Provider Name & Specialty: Provider ID Number: </p><p>Office Address: Office Phone Number: Office Fax Number: </p><p>Facility Name: Facility ID Number: </p><p>Facility Address: </p><p>Date/Date Range of Service: Place of Service: Home Inpatient Service Requested (CPT if known): Outpatient Other: Diagnosis (ICD-9) if known): </p><p>Please check all that apply to the individual:</p><p>Cochlear Implants Request is for unilateral cochlear implantation Request is for bilateral cochlear implantation Request is for an FDA-approved single channel cochlear implant Request is for an FDA-approved multi-channel cochlear implant Other: (please describe) </p><p>Initial Request: Individual has bilateral severe to profound pre- or postlingual hearing loss (sensorineural deafness) defined as a hearing threshold of 70 decibels (dB) or greater. Individual cannot benefit from conventional hearing devices Individual is free from lesions in the auditory nerve and acoustic areas of the central auditory pathway (nervous system) Individual is free from otitis media or other active middle ear infections Individual’s auditory cranial nerve can be stimulated Individual is able to participate in a post-cochlear rehabilitation program Other: (please describe) </p><p>Upgrade/Replacement request: **Please mark type of implant above** Request is for upgrade to or replacement of an existing external speech processor, controller or speech processor and controller (integrated system) Upgrade/replacement is for convenience Upgrade/replacement is to upgrade to a newer technology when the current components remain functional. Individual’s response to existing component is inadequate to the point of interfering with activities of daily living Components of current device are no longer functional. Other: (please describe) </p><p>Auditory Brain Stem Implants Request is for an FDA-approved auditory brainstem implant (ABI) Other: (please describe) </p><p>Initial Request: Individual is 12 years of age or older Individual has Neurofibromatosis Type II Individual is completely deaf as a result of the bilateral resection of neurofibromas of the auditory nerve (e.g. neurofibromatosis or von Recklinghausen’s disease) Other: (please describe) </p><p>Upgrade/Replacement Request: **Please mark type of implant above** Request is for upgrade to or replacement of an existing external sound processor, remote assistant or both components Upgrade/replacement is for convenience Upgrade/replacement is to upgrade to a newer technology when the current components remain functional. Individual’s response to existing component is inadequate to the point of interfering with activities of daily living Components of current device are no longer functional. Other: (please describe) </p><p>This request is being submitted: Pre-Claim Post–Claim. If checked, please attach the claim or indicate the claim number </p><p>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. </p><p>______Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)* Date</p><p>*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted</p><p>Page 2 of 2</p>