Fillable Cardiac Rhythm Implantable Device - Pacemaker Implantation (eviCore)

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Cardiac Rhythm Implantable Device - Pacemaker Implantation (eviCore)

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The Cardiac Rhythm Implantable Device - Pacemaker Implantation (eviCore) form is 2 pages long and contains:

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  • 20 check-boxes
  • 102 other fields

Country of origin: US
File type: PDF

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First Name: Middle Initial: Last Name:
DOB (mm/dd/yyyy ):
Gender: Male Female
Street Address: Apt #:
City: State: Zip:
Cell Phone:
Primary Contact: Home Cell
Health Plan: Member ID: Group ID:
First Name: Last Name:
Primary Specialty:
TIN: NPI:
Physician Phone: Physician Fax:
Address: Suite #:
City: State: Zip:
Office Contact: Ext:
Contact Email:
First Name: Last Name:
Group/Site Name:
Primary Specialty:
TIN: NPI:
Site Phone: Site Fax:
Address: Suite #:
City: State: Zip:
33206 33207 33208 33212
33213
33214 33221 33224 33225 33227
33228 33229 33230 33231 33240
33249 33262 33263 33264 Other:
Diagnosis, if known or rule out:
ICD-10 Codes:
Date of last visit: Retro date of service:
Page 1 of 2
Cardiac Rhythm Implantable Device - Pacemaker Implantation
Patient/Member
Home Phone:
Ordering Provider
Facility/Site
Procedure
Check all
applicable
CPT Codes:
Diagnosis
CONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacy regulations such as the
Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information is intended only for the use of the recipient (s) named above. If you are not the intended
recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of any of the information contained
in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify eviCore healthcare and destroy the original
transmission and its attachments without saving them in any manner.
For NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc.
If there are any inconsistencies with the medical office records, please elaborate in the comment section. Failure to
provide all relevant information may delay the determination. Phone
request. authorization an submit to site
the on located portal provider the into log also may You section. Forms Fax and Guidelines the under eviCore.com
on found be can numbers fax and
URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE.
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
For Symptomatic individuals:
Yes No Don't Know
Yes No Don't Know
Yes No Don't Know
For asymptomatic individuals:
Yes No Don't Know
Yes No Don't Know
Yes No Don't Know
Yes No Don't Know
Yes No Don't Know
Yes No Don't Know
Yes No Don't Know
12. Is this for a replacement device? Yes No Don't Know
Additonal information/comments:
Who is making this request? Ordering Physician Facility Other:
Print Name:
Title: MD RN LPN PA NP Other:
Signature: Date:
Page 2 of 2
7. Does the individual have second-degree AV block and documented
periods of asystole greater than or equal to 3.0 seconds?
Submitter
Clinical Information
1. Does the individual have symptomatic bradycardia (slow heart rate)?
Symptoms may include syncope, shortness of breath.
2. Does the individual have exertional limitations because their heart rate
is unable to achieve an approximate predicted heart rate of 80% (220-
age), aka “chronotropic incompetence”?
3. Does the individual have recurrent syncope caused by spontaneously
occurring carotid sinus stimulation and carotid sinus pressure that
induces ventricular asystole of more than 3 seconds?
4. Does the individual have symptomatic bradycardia when given
medications required for other medical conditions?
5. Does the individual have permanent or intermittent third-degree AV
block?
6. Does the individual have advanced second-degree (Mobitz II) AV
block or alternating bundle branch block?
8. Does the individual have atrial fibrillation and a pause of 5 seconds or
longer?
9. Will the individual have catheter ablation of the AV junction intended for
a rate control strategy for management of atrial fibrillation?
10. Does the individual have a progressive neuromuscular disease (such
as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy
(limb-girdle muscular dystrophy), and peroneal muscular atrophy) and
any degree of AV block or fascicular block?
11. Does the individual have persistent second-degree AV block in the
His-Purkinje system with alternating bundle-branch block or third-degree
AV block within or below the His-Purkinje system after myocardial
infarction?
Yes No
Don't Know
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Cardiac Rhythm Implantable Device - Pacemaker Implantation (eviCore)

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Completed 5 April 2022

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