Fillable Cardiac Rhythm Implantable Device (eviCore)

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Cardiac Rhythm Implantable Device (eviCore)

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Cardiac Rhythm Implantable Device
First Name: Middle Initial: Last Name:
DOB (mm/dd/yyyy ):
Gender: Male Female
Street Address: Apt #:
City: State: Zip:
Home Phone: 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
Patient/Member
Ordering Provider
Facility/Site
Check all
applicable CPT
Codes:
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.
Procedure
Diagnosis
Secondary prevention in a survivor of cardiac arrest due to VT or VF
without CRT, requiring an ICD
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. ationzauthori 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
Yes No Don't know
2. Is life expectancy greater than 1 year?
Yes No Don't know
3. Is routine follow-up possible?
Yes No Don't know
4. 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
Clinical Information
Submitter
Please note: if this procedure is approved and is being performed in an inpatient setting contact
the patient's health plan directly to have the inpatient admission approved after the authorization
is issued.
1. Is there a reversible cause of VT or VF? (Reversible causes of VT and VF include abnormal thyroid
function or electrolyte balance, digoxin or antiarrhythmic toxicity, idiopathic VT or VF amenable to
ablation)
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Cardiac Rhythm Implantable Device (eviCore)

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Completed 5 April 2022

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