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Cardiac - Diagnostic Heart Catheterization Imaging Request (eviCore)

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Cardiac - Diagnostic Heart Catheterization Imaging Request
First Name: Middle Initial: Last Name:
DOB (mm/dd/yyyy ):
Gender: Male Female
Street Address: Apt #:
City: State: Zip:
Home Phone: Cell Phone:
Primary Contact: Home Cell
Health Plan: Member ID: Group ID:
First Name: Last Name:
Primary Specialty:
TIN: NPI:
Physician Phone: Physician Fax:
Address: Suite #:
City: State: Zip:
Office Contact: Ext:
Contact Email:
First Name: Last Name:
Group/Site Name:
Primary Specialty:
TIN: NPI:
Site Phone: Site Fax:
Address: Suite #:
City: State: Zip:
93451 93452 93453 93454 93455
93456 93457 93458 93459 93461
93531 93532 93533 Other:
Diagnosis, if known or rule out:
ICD-10 Codes:
Date of last visit: Retro date of service:
Page 1 of 2
Patient/Member
Ordering Provider
Facility/Site
Check all
applicable CPT
Codes:
Procedure
Diagnosis
CONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacy
regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information is intended only for the use of the recipient (s)
named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any
disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have
received this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without saving
them in any manner.
For NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc. If
there are any inconsistencies with the medical office records, please elaborate in the comment section. Failure to
provide all relevant information may delay the determination. Phone
request authorization an submit to site the on located
portal provider the into log also may You section. Forms Fax and Guidelines the under .comeviCore
on found be can numbers fax and
. URGENT (same day) REQUESTS MUST BE
SUBMITTED BY PHONE.
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Yes No Don't know
2. Date of most recent office visit or contact with physician?
Date (mm/dd/yyyy): None Don't know
3. Which of the following is the main reason for this request?
Don’t know
4. Select all of the following heart procedures that have been performed:
None
PCI (coronary angioplasty or coronary stent)
CABG (Coronary Bypass Surgery)
Valve surgery
Other:
Don't know (this answer will prevent expedited approval)
5. What cardiac symptoms are present? Select all that apply. (Continued on next page).
No cadiac symptoms are present
Cardiac symptoms are present but stable
New or worsening angina or angina equivalent
New or worsening heart failure symptoms (shortness of breath)
Page 2 of 2
Clinical Information
Severe CHF (Congestive Heart Failure)
Severe proximal coronary stenosis suggested on CTCA ( Computed Tomography Coronary
Angiography)
None of the above
Stable angina (chest pain or discomfort that typically occurs with activity or stress)
Progressive angina with known CAD despite attempts at increased cardiac medication (Maximum
Medical Therapy)
Complex congenital heart disease OR, assessment of previously repaired congenital heart
disease
Planned/ staged PCI (Planned or staged coronary angioplasty or coronary stent of a recently
diagnosed coronary blockage based upon a recent heart catheterization/coronary angiogram)
Abnormal stress test with exercise duration of less than 5 minutes, AND abnormal ECG response
or abnormal cardiac stress imaging
Abnormal stress test with a large reversible ischemic zone by imaging stress test
Severe or critical valvular heart disease (Severe aortic stenosis or insufficiency; severe mitral
stenosis or insufficiency)
1. Prior authorization is required for stable cardiac conditions in the
outpatient setting. Published guidelines recommend hospitalization for
unstable angina. Is unstable angina the primary reason for this
request?
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Cardiac - Diagnostic Heart Catheterization Imaging Request (eviCore)

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Completed 5 April 2022

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