Fillable Cardiac Rhythm Implantable Device (eviCore)

Fill Online, Printable, Fillable, Blank Cardiac Rhythm Implantable Device (eviCore) Form

Use Fill to complete blank online EVICORE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Cardiac Rhythm Implantable Device (eviCore)

On average this form takes 26 minutes to complete

The Cardiac Rhythm Implantable Device (eviCore) form is 3 pages long and contains:

  • 0 signatures
  • 33 check-boxes
  • 87 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your eviCore forms online.

BROWSE EVICORE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Cardiac Rhythm Implantable Device
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:
33206
33207
33208 33212 33213
33214
33221
33224 33225 33227
33228
33229
33230 33231 33240
33249
33262
33263 33264 Other:
Diagnosis, if known or rule out:
ICD-10 Codes:
Date of last visit: Retro Date of Service:
Page 1 of 3
Patient/Member
Ordering Provider
Facility/Site
Check all
applicable CPT
Codes:
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.
Procedure
Diagnosis
Primary or secondary prevention in a client with reduced left ventricular
ejection fraction, LVEF, requiring CRT-D
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
URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHON( request. authorization an submit to site
the on located portal provider the into log also may You section. Forms Fax and Guidelines the under eviCore.com on found be can numbers fax and
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
1. Are any of the following present?
Cardiac Sarcoidosis
Chagas disease
Giant cell myocarditis
None of the above
Don't know
2. Is there evidence of any of the following?
Long-QT syndrome and a history of unexplained fainting?
Ventricular Tachycardia (VT) while receiving beta-blockers
Other risk factors for sudden death
None of the above
Don't know
Yes No Don't know
Yes No Don't know
Yes No Don't know
Page 2 of 3
Please note: if this procedure is approved and is being performed in an inpatient setting contact
the patient's health plan directly to have the inpatient admission approved after the authorization
is issued.
Clinical Information
(Cardiac Sarcoidosis: An inflammatory disease that causes granular clumps of cells similar to scar tissue
to proliferate; Chagas Disease: An illness spread by the reduvid bug. Cardiomyopathy is a common sign
of Chagas disease; Giant Cell Myocarditis: A rare cardiovascular disease where giant multi-nucleate cells
form in the heart)
(“Other risk factors” may include family history of sudden death; Long-QT syndrome = A congenital
disorder characterized by a prolongation of the QT interval on ECG and a tendency to ventricular
tachyarrhythmias, which may lead to syncope, cardiac arrest, or sudden death, For Long-QT, time
interval must be> 500 msec OR Long QT 2 or 3; “Fainting” = Syncope. List of common beta blockers:
Betapace (sotalol), Blocadren (timolol), Brevibloc (esomol), Cartrol (carteolol), Coreg (carvedilol),
Corgard (nadolol), Inderal-LA (propranolol), Kerlone (betaxolol), Levatol (penbutolol), Lopressor
(metoprolol), Normodyne (labetalol), Sectral (acebutolol), Tenormin (atenolol), Toprol-XL (metoprolol),
Trandate (labetalol), Visken (pindolol), Zebeta (bisoprolol))
3. Is there Brugada syndrome and a history of unexplained syncope? (Brugada syndrome is a genetic
disorder that can cause ventricular tachyarrhythmias that lead to syncope, cardiac arrest or sudden
cardiac death)
4. Is there HCM, and one risk factor for sudden death? (HCM = Hypertrophic Cardiomyopathy. HCM is a
disease of the heart muscle where a portion of the heart thickens without any obvious reason. Risk
factors for sudden death include: sudden fainting (unheralded syncope); family history of sudden death;
septal wall thickness of greater than or equal to 30 mm; abnormal Blood Pressure from exercising –i.e.
flat response/failure to augment; rise then fall during exercise.)
5. Is there ARVC and one risk factor for sudden death? (ARVC = Arrhythmogenic Right Ventricular
Cardiomyopathy. Risk factors for sudden death include: induction of VT during electrophysiological
testing; detection of non-sustained VT on noninvasive Monitoring; male gender; severe right ventricular
dilation; extensive right ventricular involvement; left ventricular involvement; or Unexplained syncope.)
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
CPVT with fainting
Documented sustained VT while receiving beta blockers
Don't know
Yes No Don't know
8. Is life expectancy greater than 1 year?
Yes No Don't know
9. Is routine follow-up possible?
Yes No Don't know
10. Is this for a replacement device?
Yes No Don't know
Additonal Information/Comments:
Who is making this request? Ordering Physician Facility Other:
Print Name:
Title: MD RN LPN PA NP Other:
Signature: Date:
Page 3 of 3
Submitter
6. Is there one of the following?
7. Is there familial cardiomyopathy associated with sudden death?
Clinical Information
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Cardiac Rhythm Implantable Device (eviCore)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document