WTC – 5

ICD9, CPT, HCPCS/DME Code & Medication Request Form

Submission Instructions: Please complete this form to the fullest extent possible and send it to the World Trade Center Health Program at WTCMedCode@csc.com.

Requestor:	Date of Request:	Request Urgency:

Urgency Rationale:

Section 1a: Code Request Information

Code Type:	Code Number:	Code Description:

(Please enter only one code or parent code and provide standard code naming convention.)

Rationale:

(Please provide the basis for this request, noting the particular clinical situation that precipitated this request, as well as the programmatic justification for including this code in the WTCHP.)

Section 1b: Medication Request Information

Generic Name:	Brand Name:

Route of Administration:	Dose Range:

ICD-9 Code of Condition Being Treated:	Rationale:

(Please provide the basis for this request, noting the particular clinical situation that precipitated this request, as well as the programmatic justification for inclusion of this medication into the WTCHP Formulary. If this is a new product, or off-label use, please forward any supporting literature references.)

Section 2: Requested Code/Medication Placement

Requested Category placement for ICD-9 Code Request:

If requested as WTC–Associated, to what WTC–Related Condition must it be associated?

Requested Category placement for CPT Code Request:

Requested Formulary Location:

Diagnostic	Standard Treatment	Mental Health	Transplant

Cancer Diagnostic	Cancer Treatment

Section 3: CCE Comments

Medical Director Comments:

Date Submitted: