JOHNS HOPKINS -cancer.net
Pre-Certification Request
Date: ________________
T0:__________________
From: _______________
RE: Precertification for Thyroid Cancer Management
________________________________________________________________________
_________________________ is under the care of Dr___________________ for the treatment of thyroid cancer. The patient is being prepared to undergo a coordinated set of diagnostic procedures requiring authorizations for laboratory testing and nuclear medicine procedures.
A copy of the schedule for these procedures follows. Relevant CPT codes are:
TSH: 84443
hCG :84703 (for women of child-bearing potential)
Thyroglobulin: 84432
Radioiodine dosing: 78018
Radioiodine scanning: 78006
Radioiodine treatment: 79005
Please fax (_____-____-_____) or call (____-____-____) to authorize performance of these procedures.
If you have any questions please call _________________ at _______________.
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