Revised 122921 CM-FRM-0117-015
Ablative and Surgical Treatment for Venous Insufficiency
Refer to the back of the patient’s ID card under the heading Prior Authorization for the
appropriate contact information.
Date of request: Anticipated service date:
Patient name: Phone:
ID number: Date of birth:
Member address:
Physician:
Tax ID:
Address:
Contact:
Phone: Ext. Fax:
DX: ICD-10 code:
List all proposed CPT/procedure codes:
Please specify for each code what vein is being requested and if Bilateral, Right or Left:
IMPORTANT: In addition to this form, submit:
__ Complete history and physical
__ Pre-operative examination with most recent Doppler/duplex scanning reports that include reflux
and vein diameter measurements; Post-procedure Doppler report if applicable.
__ Documentation of conservative and adjunctive measures, including duration and outcome.
__ Activities the member must modify or cannot perform due to varicose vein conditions.
Submit completed form and supporting documents to:
GEHA Fax: 816.257.3255 or
P.O. Box 21542 Secure email:
Eagan MN 55121 caremanagementsurgery@geha.com
Questions: Call GEHA at 800.821.6136, ext. 3100.
All benefit payments are subject to review for any applicable deductibles, coinsurance, maximums, medical
necessity and patient eligibility on the date that the service is provided, or the supply delivered.
