Continuous Passive Motion Devices

REVIEW REQUEST FOR

Continuous Passive Motion Devices

Provider Data Collection Tool Based on Medical Policy DME.00019

Policy Last Review Date: 08/19/2010 / Policy Effective Date: 10/13/2010 / Provider Tool Effective Date: 10/13/2010
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
Outpatient Other:
Service Requested (CPT if known):
Diagnosis (ICD-9) if known):

Please check all that apply to the individual:

Request is for Continuous Passive Motion (CPM) device applied within 72 hours following surgery

Request is for CPM use for longer than 21 days from date of first application

Other: (please list)

Individual is status post anterior cruciate ligament (ACL) repair

Individual is status post articular osteochondral repair procedures of the knee (such as microfracture, osteochondral

grafting, autologous chondrocyte implantation (ACI), meniscal allograft, treatment of osteochondritis dissecans, repair of

tibial plateau fractures

Individual is status post posterior cruciate ligament (PCL) repair

Individual is status post total knee arthroplasty (TKA) or TKA revision

Request is subsequent to arthroplasty or the release of an arthrofibrosis of the elbow or knee, shoulder, wrist or hand. (e.g.

elbow arthroplasty, rotator cuff repair or arthroplasty or metacarpal joint phalangeal arthroplasty)

Request is for any of the following (check all that apply):

Treatment of ankle or toe conditions

Treatment of chronic contractures

Treatment of degenerative joint diseases

Treatment of distal radial fractures

Treatment of idiopathic club foot in infants

Treatment of stroke with hemiparesis

Treatment of TMJ (temporomandibular joint)

Other (explain):

Device was initially applied in an inpatient setting prior discharge

Date of surgery

Date of device application

Discharge date

Other uses: (please list)

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

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.

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