Fillable Precertification Information Request Form Varicose Vein Treatment (Aetna Health Insurance)

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Precertification Information Request Form Varicose Vein Treatment (Aetna Health Insurance)

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Page 1 of 4
PCFX
Varicose Vein Treatment
Precertification Information Request Form
Applies to:
Aetna plans
Innovation Health® plans
Health benefits and health insurance plans offered, underwritten and/or
administered by the following:
Allina Health and Aetna Health Insurance Company (Allina Health | Aetna)
Banner Health and Aetna Health Insurance Company and/or Banner Health and
Aetna Health Plan Inc. (Banner | Aetna)
Sutter Health and Aetna Administrative Services LLC (Sutter Health | Aetna)
Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance
Company (Texas Health Aetna)
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including
Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services on behalf of its affiliates.
GR-68807-2 (6-20)
Page 2 of 4 GR-68807-2 (6-20)
About this form
You can’t use this form to initiate a precertification request. To initiate a request, call our Precertification Department or you can
submit your request electronically. Failure to complete this form and submit the medical records we are requesting may result
in the delay of review.
This form replaces all other Varicose Vein Treatment precertification information request documents and forms. This form will help you
supply the right information with your precertification request. You don’t have to use the form. But it will help us adjudicate your
request more quickly.
How to fill out this form
As the patient’s attending physician, you must complete all sections of the form. You can use this form with all Aetna health plans,
including Aetna’s Medicare Advantage plans. You can also use this form with health plans for which Aetna provides certain
management services.
When you’re done
Once you’ve filled out the form, submit it and all requested medical documentation to our Precertification Department by:
We prefer you submit precertification requests electronically. Use our provider portal on Availity® to also upload
clinical documentation, check statuses, and make changes to existing requests. Register today at
availity.com/aetnaproviders.
Precertification- Commercial and Medicare (including expedited) using FaxHub: 1-833-596-0339
o The fax number above (FaxHub) is for clinical information only. Please send specific information that supports
your medical necessity review. Please continue to send all other information (claims etc) to appropriate fax
numbers. Thank you.
Email requests that require photographs to:
o Commercial Plans: VFAXPrecert@aetna.com
o Medicare Advantage Plans: MedicarePrecert@aetna.com
Mail your information to: PO Box 14079 Lexington, KY 40512-4079
PCFX
Varicose Vein Treatment
Precertification Information Request Form
What happens next?
Once we receive the requested documentation, we’ll perform a clinical review. Then we’ll make a coverage determination and let
you know our decision. Your administrative reference number will be on the electronic precertification response.
How we make coverage determinations
If you request precertification for a Medicare Advantage member, we use CMS benefit policies, including national coverage
determinations (NCD) and local coverage determinations (LCD) when available, to make our coverage determinations. If there
isn’t an available NCD or LCD to review, then we’ll use the Clinical Policy Bulletin referenced below to make the determination.
For all other members, we encourage you to review Clinical Policy Bulletin #50: Varicose Veins, before you complete this
form.
You can find the Clinical Policy Bulletins and Precertification Lists by visiting the website on the back of the member’s ID card.
Questions?
If you have any questions about how to fill out the form or our precertification process, call us at:
HMO plans: 1-800-624-0756
Traditional plans: 1-888-632-3862
Page 3 of 4 GR-68807-2 (6-20)
Varicose Vein Treatment
Precertification Information Request Form
- -
- - -
Section 1: Provide the following general information
If submitting request electronically, complete member name, ID and reference number only
Member name: Reference number (required):
Member ID: Member date of birth:
Requesting provider/facility name:
Requesting provider/facility NPI:
Requesting provider/facility phone number: 1
Requesting provider/facility fax number: 1
Assistant/co-surgeon name (if applicable): TIN:
Section 2: Provide the following patient-specific information.
Select any of the following the patient has experienced:
Incompetence (i.e., reflux) at the saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ) documented by
Doppler of duplex ultrasound scanning?
Left leg: SFJ SPJ
Right leg: SFJ SPJ
Intractable ulceration secondary to venous stasis
More than one episode of minor hemorrhage from a ruptured superficial varicosity
Single significant hemorrhage from a ruptured superficial varicosity
Was a blood transfusion required? Yes No
Recurrent superficial thrombophlebitis
Severe and persistent pain and swelling interfering with activities of daily living and requiring chronic analgesic
medication
Has the patient had any of the following procedures in the same anatomical location on the same leg?
(check all that apply; indicate date(s) of each treatment)
Great saphenous vein or small saphenous vein ligation / division / stripping
Left leg date(s) Right leg date(s)
Radiofrequency endovenous occlusion (VNUS procedure)
Left leg date(s) Right leg date(s)
Endovenous laser ablation of the saphenous vein (ELAS) - also known as endovenous laser treatment (EVLT)
Left leg date(s) Right leg date(s)
Sclerotherapy (liquid or foam)
Left leg date(s) Right leg date(s)
Ambulatory phlebectomy or transilluminated powered phlebectomy (TriVex System)
Left leg date(s) Right leg date(s)
Other (please specify procedure):
Left leg date(s) Right leg date(s)
Varicose Vein Treatment
Precertification Information Request Form
Member ID: Reference number:
Section 2 Continued: Provide the following patient-specific information
Has the patient used any of the following for conservative management? (check all that apply)
Analgesic Medication(s)- pain medications/anti-inflammatories:
Medication: Dates of use: Results:
Medication: Dates of use: Results:
Prescription gradient support stockings
Dates of use: Results:
Has the patient attempted a 3-month period of conservative management including: Yes No
Section 3: Provide the following general information
/ /
- - -
/ /
Date of procedure:
Are all codes anticipated to be performed on a single date of service? Yes No
Diagnosis code(s):
CPT/HCPCS codes and corresponding vein, descriptions that best describe the service(s) you’ll provide. (For
drugs/inject
ables, include any administration codes.)
Section 4: Provide the following documentation for your request
Current history and physica
l
All supporting medical records documenting clinical findings, including the following:
- Signs and symptoms, including member’s complaint; and, duration and severity of varicose vein condition
- Physical findings
Doppler or duplex ultrasound scanning study performed within the past 6 months (submit actual reports):
- Junctional reflux duration in the saphenofemoral or saphenopopliteal vein to be treated
- Vein diameter bel
ow the saphenofemoral and below the saphenopopliteal junction
Clinical records documenting the following:
- Activities the patient must modify or eliminate due to pain and swelling caused by varicose veins.
- The conservative management the patient has attempted to control pain and swelling, including the outcome.
- Plan of care for treatment of the varicose vein(s)
Section 5: Read this important information
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure,
defraud or deceive any insurance company by providing materially false information or conceals material information for the purpose of
misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Section 6: Sign the form
Just remember: You can’t use this form to initiate a precertification request. To initiate a request, call our Precertification Department or
you can submit your request electronically.
Signature of person completing form :
Date:
Contact name of office personnel to call with questions:
Telephone number: 1
Page 4 of 4 GR-68807-2 (6-20)
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Completed 18 August 2021

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