CMN_Solid_Organ_Transplant_Final - Florida Blue
|Certificate of Medical Necessity: |[pic] |
|Solid Organ Transplants | |
| |
|Fax or email this completed form | |Fax: (904) 357-6331 |
|and other required documentation including letter of | |Email: centralizedtransplantunit@ |
|medical necessity from physician, patient history of illness, | |Phone: 1 (800) 955-5692 Extension: 19001 |
|all pertinent laboratory findings, diagnostic testing including radiology | | |
|reports, and other pertinent documentation | | |
|Section A |
|Physician Information/ |Name: |BCBSF No: |National Provider Identifier (NPI): |
|Requesting Provider | | | |
| |Contact Name: |Phone: |
|Facility Information/ |Name: |BCBSF No: |National Provider Identifier (NPI): |
|Location where services will be| | | |
|rendered | | | |
| |Contact Name: |Phone: |
|Transplant Coordinator |Name: |Phone: |Fax: |
|Financial Coordinator |Name: |Phone: |Fax: |
|Member Information |Last Name: |First Name: | Male Female |
| |Member/Contract Number (alpha and numeric): |Date of Birth: |
|Procedure Information |Procedure Code(s): |Procedure Description: |
| |Diagnosis code(s): |Diagnosis Description: |
| |Date of Service/Tentative Date: |
|Member Status | This is an urgent request | Member is currently in-member |
|Coding |ICD-9 codes: |
| |Diagnosis codes description (Including co-morbidities): |
|Section B – General Information |
Check all boxes and complete all entries that apply:
|What type of end-stage organ disease does the member have? Check all the apply: |
| | |Heart | |Pancreas | |Multiple Visceral (specify organs) |
| | |Heart/Lung | |Kidney | |Small Bowel |
| | |Lung | |Liver | |Pancreatic Islet Cell |
|The member will receive: |
| | |Living organ | |Cadaveric organ |
|Section C – Current Medical Information |
Check all boxes and complete all entries that apply:
| Yes | No |Does the member have any psychosocial conditions or chemical dependency affecting ability to adhere to therapy? |
| Yes | No |Is the member actively involved in alcohol or drug abuse treatment? |
| | |If Yes, |
| | |provide date treatment began: |
| | |Attach a copy of the most recent drug screen including date collected. |
| Yes | No |Does the member have an untreated systemic infection making immunosuppression unsafe, including chronic infection? |
| Yes | No |Does the member have systemic disease that could be exacerbated by immunosuppression? |
| Yes | No |Does the member have any serious health conditions that create an inability to tolerate surgery or post-transplant care? |
| Yes | No |Does the member have an untreatable end-stage disease of another organ? |
| | |If Yes, explain: |
| Yes | No |Does member have adequate support system in place? |
| Yes | No |Does the member have a known, current malignancy? If Yes, attach documentation of type, location, and treatment. |
| Yes | No |Does the member have a recent malignancy with a high rate of recurrence? |
| Yes | No |Has the entire transplant evaluation workup been completed? |
|Section D – Organ Specific Information |
Check all boxes and complete all entries that apply:
|Heart - Adult |
|Which of the following indications is applicable for the member? |
| | |Heart failure with evidence of maximal VO2 ................
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