Fillable Clinical Information Request for Cardiac Implantable Devices (eviCore)

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Clinical Information Request for Cardiac Implantable Devices (eviCore)

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The Clinical Information Request for Cardiac Implantable Devices (eviCore) form is 3 pages long and contains:

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Clinical Information Request for Cardiac Implantable Devices
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:
Diagnosis, if known or rule out:
ICD-10 Codes:
Date of last visit:
What Cardiac Implantable Device is being requested?
33206 Single Chamber Atrial Pacemaker: AAI insertion with lead placement
33207 Single Chamber Ventricular Pacemaker: VVI insertion with lead placement
Page 1 of 3
Patient/Member
Ordering Provider
Facility/Site
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.
Diagnosis
Procedure
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 eviCore.com
on found be can numbers xfa 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
What Cardiac Implantable Device is being requested? (cont'd)
33208 Dual Chamber Pacemaker: DDD insertion with lead placement
33212 Single Chamber Atrial or Ventricular Pacemaker: AAI/VVI insertion without lead placement
33213 Dual Chamber Pacemaker: DDD insertion without lead placement
33214 Dual Chamber Pacemaker: DDD Upgrade From Single Chamber Device with lead placement
33221 Cardiac Resynchronization Therapy: CRT-P insertion without lead placement
33224 Cardiac Resynchronization Therapy: CRT-P/D Upgrade with lead placement
33225 & 33208 Cardiac Resynchronization Therapy: CRT-P Insertion with lead placement
33225 & 33229 Cardiac Resynchronization Therapy: CRT-P Upgrade from Dual Chamber Pacemaker
33225 & 33249 Cardiac Resynchronization Therapy: CRT-D Insertion with lead placement
33225 & 33264 Cardiac Resynchronization Therapy: CRT-D Upgrade from Dual Chamber ICD
33227 Single Chamber Atrial or Ventricular Pacemaker: AAI/VVI removal & replacement without lead
33228 Dual Chamber Pacemaker: DDD removal & replacement without lead placement
33229 Cardiac Resynchronization Therapy-P: CRT-P removal & replacement without lead placement
33230 Implantable Cardioverter-Defibrillator: ICD insertion without leads-DDD pacemaker
33231 Cardiac Resynchronization Therapy-D: CRT-D insertion without lead placement
33240 Implantable Cardioverter-Defibrillator: ICD insertion without leads - VVI pacemaker
33249 Implantable Cardioverter-Defibrillator: ICD insertion with leads - DDD or VVI pacemaker
33262 Implantable Cardioverter-Defibrillator: ICD removal & replacement without leads – VVI pacemaker
33263 Implantable Cardioverter-Defibrillator: ICD removal & replacement without leads – DDD pacemaker
33264 Cardiac Resynchronization Therapy-D: CRT-D removal & replacement without lead placement
The clinical information below may be required to process your request.
If requested Electrophysiologic report summary
If requested Imaging report documenting left ventricular dysfunction
If requested Imaging report documenting the ejection fraction
If requested Holter monitor or event monitor summary report
If requested Electrocardiogram
If requested Office note documenting NYHA heart failure classification and medical management
Additional Information/Comments:
Page 2 of 3
Procedure (cont'd)
Clinical Information
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Additional Information/Comments (cont'd)
Who is making this request? Ordering Physician Facility Other:
Print Name:
Title: MD RN LPN PA NP Other:
Signature: Date:
Page 3 of 3
Clinical Information
Submitter
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Clinical Information Request for Cardiac Implantable Devices (eviCore)

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Completed 22 October 2021

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