Immune Globulin (IG) Therapy Medication and/or Infusion ...

Aetna Precertification Notification Immune Globulin (IG) Therapy Medication 503 Sunport Lane, Orlando, FL 32809. and/or Infusion Precertification Request Phone: 1-866-503-0857. Page 1 of 3 FAX: 1-888-267-3277. (All fields must be completed and legible for Precertification Review.). For Medicare Advantage Part B: Please indicate: Start of treatment: Start date / / FAX: 1-844-268-7263. Continuation of Therapy : Date of last treatment / /. Precertification Requested By: Phone: Fax: A. PATIENT INFORMATION. First Name: Last Name: Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: DOB: Allergies: Email: Current Weight: lbs or kgs Height: inches or cms B.

Were electrodiagnostic studies (electromyography [EMG] or nerve conduction studies [NCS]) and the evaluation of cerebrospinal fluid (when available) performed to confirm the diagnosis? Yes . No . Churg-Strauss Syndrome. Yes. No . Does the patient have severe, active disease? Yes . No. Will immune globulin be used as adjunctive therapy? Yes . No

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  Studies, Medication, Therapy, Never, Immune, Globulin, Conduction, Immune globulin, Nerve conduction studies, Therapy medication

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