Prior Authorization request for Varicose Vein Treatment

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* Required Field

Enter Patient Information

  • Review Type:
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • IDC-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.
  • Date of Service/Admission Date: *

* Required Field

Enter Provider Information

  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address:
  • Contact Phone No:*
  • Contact Phone Ext:
  • Contact Fax No:*
  • Provider ID OR NPI: *
  •  
    • I am an Ordering Physician
    • I am a Servicing Physician
  • Ordering Physician's Name:
  • Ordering Physician's Address:
  • Ordering Physician's City:
  • Ordering Physician's State:
  • Ordering Physician's Zip:
  • Ordering Physician's Email Address:
  • Ordering Physician's Phone No:
  • Ordering Physician's Fax No:
  • Servicing Physician's Name:
  • Servicing Physician's Address:
  • Servicing Physician's City:
  • Servicing Physician's State:
  • Servicing Physician's Zip:
  • Servicing Physician's Email Address:
  • Servicing Physician's Phone No:
  • Servicing Physician's Fax No:
  • Facility/Supplier Name: *
  • Facility NPI:
  • Facility/Supplier Address: *
  • Facility/Supplier City: *
  • Facility/Supplier State: *
  • Facility/Supplier Zip: *

Check all that apply:

  • Symptoms:
  • Pain
  • Swelling
  • Itching
  • Burning
  • Hemorrhage of superficial veins
  • Leg Ulcers/Size/Duration
  • Associated w/ Perforator:
    No Yes
  • Conservative Tx: Compression Stockings NSAIDS Other:

How long have conservative measures been tried?

  • Do symptoms significantly interfere with ADLs?
  • No
  • YesHow?

Patient has had previous endovenous ablation to:

  • Right GSVDate of Procedure:
  • Right SSVDate of Procedure:
  • Left GSVDate of Procedure:
  • Left SSVDate of Procedure:

Please fill out a separate line for each vein for which you are requesting treatment.

Example:

Procedure LT/RT Vein Size (mm) Reflux Seconds Tributary Perforator # Txs Sclero  
36475 R GSV 5.8 mm Yes 1.2 N/A N/A N/A  
36471 L Tribs 4.3 - 5.7 Yes 0.9 Yes N/A 2  
Procedure LT/RT Vein Size (mm) Reflux Seconds Tributary Perforator # Txs Sclero  

Please attach relevant clinical documentation. *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







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If you experience issues submitting this form, please print and fax it to (816) 817-8211.

If you have questions, contact Blue KC at (816) 395-3989.

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Suffix

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