Vagus nerve stimulation prior authorization request form Form

Prior Authorization Request Form for Vagus Nerve Stimulation Submit to: Behavioral Health Utilization Management Fax: 1-877-234-4273 For assistance, please call: 1-855-301-5512 Please complete all sections of this form as thoroughly as possible. You may also include any additional clinical information pertinent to this authorization request. Date: MEMBER INFORMATION Member name: Member ID number: Date of birth: Age: PROVIDER INFORMATION Provider name: Provider NPI/tax ID number: Provider address: Provider phone: Provider fax: Place of service: □ Ambulatory surgery center □ Hospital outpatient □ Hospital inpatient □ Provider’s office □ Other: Name, NPI number, and phone and fax numbers for the above place of service: Name: NPI number: Phone number: Fax number: PROCEDURE INFORMATION Requested service or procedure: Scheduled date of service (month/day/year): Procedure code(s): Primary diagnosis with code: Secondary diagnosis with code: Tertiary diagnosis with code: Please answer all of the following questions:

1. Member is 18 years of age or older? □ Yes □ No
2. Member is pregnant or breast feeding? □ Yes □ No
3. Device being used is FDA approved? □ Yes □ No For depression:
4. Member has a diagnosis of major depressive disorder, single or recurrent? □ Yes □ No
5. Member has failed four or more antidepressant trials from two diferent pharmacological classes or three or more antidepressant trials from two diferent pharmacological classes and an augmenting agent due to lack of improvement or intolerable side efects? □ Yes □ No
6. Continued depressive symptoms after completion of one course of electroconvulsive therapy (ECT) treatment? □ Yes □ No
7. No contraindications noted? (Select all that apply.) □ No acute or chronic psychotic symptoms □ No imminent risk known (e.g., suicidal ideation)
   □ No current or known substance use at the time of treatment □ No neurological conditions (e.g., dementia) □ No left cervical vagotomy by history □ No cardiac pacemaker or implantable cardioverter defbrillator Page 1 of 2

Prior Authorization Request Form for Vagus Nerve Stimulation For epilepsy:

1. Member is diagnosed with refractory epilepsy and has had epilepsy surgery? □ Yes □ No • Epilepsy is confrmed by EEG? □ Yes □ No • Member has experienced continued seizure activity after epilepsy surgery? □ Yes □ No
2. Member is diagnosed with refractory epilepsy and is not a candidate for epilepsy surgery
   or the member is diagnosed with generalized seizure disorder? □ Yes □ No • Member has failed antiepileptic drug therapy? □ Yes □ No • Member experienced continued seizure activity despite medication? □ Yes □ No • Seizure activity negatively afects activities of daily living? □ Yes □ No • Epilepsy confrmed by EEG? □ Yes □ No Provider or requestor signature: Date: ACDE_1787975 Page 2 of 2 SIGN