CMN_Solid_Organ_Transplant_Final



|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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