// (Proposed) Admission date: ICD-9-CM DIAGNOSIS NARRATIVE DESCRIPTION(S) CODE(S) 1. Scheduled Date ICD-9-CM Procedure Code(s) Procedure Description(s) // // // // Stenosis in one or more vessels Yes No If yes, vessels affected/percentage____________________________________ Failed PCI Yes No Graft(s) occluded Yes No Coronary Artery Anomalies Yes No Unstable angina Yes No If yes, still present with treatment Yes No Diabetes Mellitus Yes No Heart failure/Congestive Heart Failure Yes No If yes, is it newly diagnosed Yes No PAST TREATMENTS List results of any treatments not described in clinical indications section: Participant Medicaid ID Number: // _________________________________ Participant Last/First/Middle Name: Date of Birth: the date and results of pertinent labs, studies & tests) Results/Findings Date- if available/applicable Lab/Study/Test // Heart Catheterization // EKG // Stress Test //
(Proposed) Admission date: // ICD-9-CM DIAGNOSIS CODE(S) NARRATIVE DESCRIPTION(S) 1. Scheduled Date ICD-9-CM Procedure Code(s) Procedure Description(s) // // // // Stenosis in one or more vessels Yes No If yes, vessels affected/percentage____________________________________ Failed PCI Yes No Graft(s) occluded Yes No Coronary Artery Anomalies Yes No Unstable angina Yes No If yes, still present with treatment Yes No Diabetes Mellitus Yes No Heart failure/Congestive Heart Failure Yes No If yes, is it newly diagnosed Yes No PAST TREATMENTS List results of any treatments not described in clinical indications section: Participant Medicaid ID Number: Participant Last/First/Middle Name: _________________________________ Date of Birth: // the date and results of pertinent labs, studies & tests) Date- if available/applicable Lab/Study/Test Results/Findings // Heart Catheterization // EKG // Stress Test //
Template%20Prior%20Auth%20for%20Elective-CABG.docx