Breast Reduction Step 1 of 4 25% Member Information Enter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#* Member's DOB* MM slash DD slash YYYY Date of service (if known) MM slash DD slash YYYY Member's Name* First Last Error Message Facility InformationRendering facility NPI* 10 digitsRendering facility name* Error Message Ordering MD* Phone #*Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationCPT Code(s) and units for each*CPT CodeUnits Example CPT code: 12345Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Describe symptoms; please include presence or absence of well-defined shoulder grooving:*Describe medical treatment received for any persistent, long standing back, neck, shoulder or other musculoskeletal pain attributed to large breasts: (Needs to be 6 weeks of treatment)*Start Date (for treatment described above)* MM slash DD slash YYYY End Date (for treatment described above)* MM slash DD slash YYYY For women >40, a mammogram must be completed within one year prior to surgery. Please submit report documenting no evidence of breast cancer with this request.Has counseling regarding breast-feeding occurred and is documented?*Has counseling regarding breast-feeding occurred and is documented? *YesNoPlease comment on future plans for breast-feeding*Describe estimated removal of breast tissue per breast* Attach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician or Licensed Provider*Signature Date* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Upload only PDF or Word DocumentSignature of Physician or Licensed Provider (Required for Expedited request)*Signature Date* CommentsAuthorization is not a guarantee of paymentCAPTCHA