CMN - Genetic Testing for Hereditary Breast and Ovarian Cancer



|Certificate of Medical Necessity |[pic] |

|Treatments for Varicose Veins/Venous Insufficiency |

|Please fax completed CMN forms and other required documentation | |Statewide Fax Number:1.813.806.1233 |

|(i.e., physician history and physical, ultrasound report). | | |

|Section A |

Physician 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:       |Age:       |

Procedure Information

|Procedure Code:       |Procedure Description:       |

|ICD-9 Code:       |Diagnosis Description:       |

|What treatment modality is being used (i.e. ablation, sclerotherapy)?       |

|What types of veins are being treated (i.e. accessory, tributary, etc.)?       |

|What size are the veins?       |

|Section B |

Complete ALL the following questions. For bulleted questions, check the appropriate indicator(s).

Use the comments field on the last page to provide details.

| Yes No |Is the request for one of the following techniques and conditions? |

| | |Sclerotherapy of perforator, greater or lesser saphenous, or accessory saphenous veins OR |

| | |Sclerotherapy of isolated tributary veins without prior or concurrent treatment of saphenous veins OR |

| | |Stab avulsion, hook phlebectomy, or transilluminated powered phlebectomy of perforator, greater or lesser saphenous, or accessory |

| | |saphenous veins OR |

| | |Endovenous radiofrequency or laser ablation of tributary veins OR |

| | |Endovenous cryoablation of any vein OR |

| | |Endomechanical ablative approach (e.g. ClariVein™ Catheter) OR |

| | |Is the request for treatment of telangiectasia such as spider veins, angiomata, or hemangiomata? OR |

| | |Is the request for ultrasound (US) guidance for sclerotherapy of the non-saphenous veins (varicose tributaries)? |

| Yes No |Is the request for treatment of the greater or lesser saphenous veins? |

| | |

| |Are ALL of the following criteria met for the treatment of the greater or lesser saphenous veins by surgery (ligation and stripping) or |

| |endovenous radiofrequency or laser ablation for symptomatic varicose veins/venous insufficiency? |

| | |There is demonstrated saphenous reflux AND |

| | |The varicosities are at least 3 millimeters in size AND |

| | |There is documentation of one or more of the following indications: |

| | | |Ulceration secondary to venous stasis that fails to respond to compressive therapy OR |

| | | |Recurrent superficial thrombophlebitis that fails to respond to compressive therapy OR |

| | | |Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity OR |

| | | |Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux, AND the symptoms|

| | | |significantly interfere with activities of daily living, AND conservative management including compression therapy |

| | | |for at least 3 months has not improved the symptoms. |

| Yes No |Is the request for treatment of accessory saphenous veins? |

| | |

| |Are ALL of the following criteria met for the treatment of accessory saphenous veins by surgery (ligation and stripping) or endovenous |

| |radiofrequency or laser ablation for symptomatic varicose veins/venous insufficiency? |

| | |The greater or lesser saphenous veins had been previously eliminated (at least 3 months) AND |

| | |There is demonstrated accessory saphenous reflux AND |

| | |The varicosities are at least 3 millimeters in size AND |

| | |There is documentation of one or more of the following indications: |

| | | |Ulceration secondary to venous stasis that fails to respond to compressive therapy OR |

| | | |Recurrent superficial thrombophlebitis that fails to respond to compressive therapy OR |

| | | |Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity OR |

| | | |Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux, AND the symptoms|

| | | |significantly interfere with activities of daily living, AND conservative management including compression therapy |

| | | |for at least 3 months has not improved the symptoms. |

| Yes No |Is the request for treatment of symptomatic varicose tributaries? |

| | |

| |Is one of the following treatments a component of the treatment for symptomatic varicose tributaries when performed either at the same |

| |time or following prior treatment (surgical, radiofrequency or laser) of the saphenous veins? |

| | |Stab avulsion |

| | |Hook phlebectomy |

| | |Sclerotherapy |

| | |Transilluminated powered phlebectomy |

| Yes No |Is the request for treatment of incompetent perforator veins? |

| | |

| |Are ALL of the following criteria met for surgical ligation (including subfascial endoscopic perforator surgery) or endovenous |

| |radiofrequency or laser ablation of incompetent perforator veins as a treatment of leg ulcers associated with chronic venous |

| |insufficiency? |

| | |There is demonstrated perforator reflux AND |

| | |The varicosities are at least 3 millimeters in size AND |

| | |The superficial saphenous veins (greater, lesser, or accessory saphenous and symptomatic varicose tributaries) have been |

| | |previously eliminated AND |

| | |Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months AND |

| | |The venous insufficiency is not secondary to deep venous thromboembolism. |

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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