BotulinumToxinsCertificateofMedicalNecessity
|Certificate of Medical Necessity |[pic] |
Botulinum Toxins
|Fax this completed Certificate of Medical Necessity form along with other required | |Statewide Fax Number: 1-904-905-9849 |
|documentation including the history and physical, recent office notes (to include | | |
|patient’s symptoms and previously attempted conservative treatments, physical | | |
|examination): | | |
|Section A |
Physician Information
|Name: |BCBSF Number: |National Provider Identifier (NPI): |
|Street Address: |
|City: |County: |State: |ZIP: |
|Telephone Number: |Fax Number: |
|Contact Name: |
Facility Information
|Name: |BCBSF Number: |National Provider Identifier (NPI): |
|Street Address: |
|City: |County: |State: |ZIP: |
|Telephone Number: |Fax Number: |
|Contact Name: |
Member Information
|Last Name: |First Name: |
|Member/Contract Number (alpha and numeric): |Date of Birth: |
|Section B |
|Procedure Code (HCPCS): |Medication Name: |
|ICD-9 Code: |Diagnosis Description: |
|This medication is: administered by the Provider. self-administered by the patient. |
| Yes No N/A Is patient picking up medication at a retail pharmacy? |
| Yes No N/A Is provider buying the medication and billing BCBSF directly? |
| Yes No N/A Is provider obtaining medication from Caremark for drug replacement? |
|This is: an initial request. a continuation of therapy. |
| |
|If continuation, what date was therapy initiated? / Current Daily Dosage: |
| |
|If restart, what dates was therapy previously used? / Why was therapy stopped and restarted? |
|Prescribed Dosage: |Dosing Frequency: |Dosing administration route: |
|Section C |
Check the box and complete the questions applicable to the patient’s condition:
| Strabismus or blepharospasm |
|Yes No |
|Associated with dystonia, including benign essential blepharospasm or VII nerve disorders in patients 12 years of age and older |
| |
| Cervical dystonia (spasmodic torticollis) of moderate or greater severity |
|Yes No |
|Must be associated with sustained head tilt OR |
| |
|Yes No |
|Abnormal posturing with limited range of motion in the neck AND |
| |
|Yes No |
|A history of recurrent involuntary contraction of one or more of the muscles of the neck (e.g., sternocleidomastoid, splenius, trapezius, or posterior cervical|
|muscles) |
| |
| Severe primary axillary hyperhidrosis |
|Yes No |
|Inadequately managed with topical agents AND |
| |
|Yes No |
|Is unresponsive or unable to tolerate pharmacotherapy prescribed for excessive sweating (e.g., anticholinergics, beta-blockers, or benzodiazepines) if sweating|
|is episodic AND |
| |
|Yes No |
|Patient has medical complications such as skin maceration with secondary infections or significant functional impairments |
| |
| Focal upper limb dystonia (e.g., organic writer’s cramp) |
|Oromandibular dystonia (orofacial dyskinesia, Meige syndrome) |
|Laryngeal dystonia (adductor spasmodic dysphonia) |
|Idiopathic (primary or genetic) torsion dystonia |
|Symptomatic (acquired) torsion dystonia |
|Cerebral palsy |
|Spasticity related to stroke |
|Acquired spinal cord or brain injury |
|Hereditary spastic paraparesis |
|Spastic hemiplegia |
|Neuromyelitis optica |
|Multiple sclerosis or Schilder’s disease |
|Yes No |
|Resulting in functional impairment (interference with joint function, mobility, communication, nutritional intake) OR |
| |
|Yes No |
|Pain exists as a result |
| |
| Esophageal achalasia |
|Yes No |
|Must have tried and not responded to dilation therapy OR |
| |
|Yes No |
|Considered poor surgical candidate |
| |
| Sialorrhea (drooling) |
|Yes No |
|Associated with Parkinson disease OR |
| |
|Yes No |
|Associated with severe developmental delays when oral therapy fails (e.g., glycopyrrolate) OR |
| |
|Yes No |
|Associated with Cerebral Palsy when oral therapy fails (e.g., glycopyrrolate). |
| |
| Chronic anal fissure |
|Yes No |
|Must have failed conservative treatment (e.g., nitroglycerin ointment) |
| |
| Incontinence due to detrusor over reactivity (urge incontinence) |
|Yes No |
|Idiopathic OR |
| |
|Yes No |
|Due to neurogenic causes (e.g., spinal cord injury, multiple sclerosis) inadequately controlled with anticholinergic therapy |
| |
| Palmar hyperhidrosis |
|Yes No |
|Inadequately managed with topical agents AND |
| |
|Yes No |
|Inadequately managed with pharmacotherapy (e.g., anticholinergics, beta-blockers, or benzodiazepines, unless clinically contraindicated) AND |
| |
|Yes No |
|Patient has medical complications such as skin maceration with secondary infections or significant functional impairments |
| |
| Prevention of chronic migraine headaches (initial 6-month trial of |
|botulinum toxin for prevention of chronic migraine headaches) |
|Yes No |
|Adult individual diagnosed with chronic migraine headache AND |
| |
|Yes No |
|Fifteen (15) or more migraine days per month with headache lasting four (4) hours or longer AND |
| |
|Yes No |
|First episode at least six (6) months ago AND |
| |
|Yes No |
|Symptoms persist despite trials of at least 2 months (60 days) of at least 1 agent in a minimum of 2 of the following classes of medications used to prevent |
|migraines or reduce migraine frequency: |
|Antidepressants (e.g., amitriptyline, nortriptyline, doxepin) |
|Beta blockers (e.g., atenolol, metoprolol, nadolol, propanolol, timolol) |
|Angiotension-converting enzyme inhibitors/angiotensin II receptor blockers (e.g., lisinopril, candesartan) |
|Antiepileptics (e.g., valproate, topiramate, gabapentin) |
|Calcium channel blockers (e.g., diltiazem, nifedipine, nimodipine, verapamil). |
| |
| Prevention of chronic migraine headaches (continuing treatment with |
|botulinum toxin injection for ongoing prevention of chronic migraine headaches) |
|Yes No |
|Migraine headache frequency was reduced by at least 7 days per month (when compared to pre-treatment average) by the end of the initial trial OR |
| |
|Yes No |
|Migraine headache duration was reduced by at least 100 total hours per month (when compared to the pre-treatment average) by the end of the initial trial. |
| |
| Unlisted condition (please be sure to include supporting clinical notes for any unlisted conditions). |
Comments:
| |
My signature below certifies that the information submitted on this form is accurate and these services are medically necessary.
|Ordering Physician’s Signature: |Date: |
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