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Predetermination Form

For all patient referrals, please complete the online pre-determination form. In separate files please submit the supporting clinical documentation required.

Download blank Sirtex Patient Consent Form.

For questions related to pre-determination, please contact the pre-determination team by phone at 888-4-SIRTEX (474-7839) ext. 717 or email sirtexhelp@sirtex.com. If you are unable to upload the clinical or consent files, please send them via fax to 877-642-7888.

If you have questions related to reimbursement or medical policy, please contact the reimbursement team at usreimbursement@sirtex.com.


SIR-Spheres® Y-90 resin microspheres Predetermination Form

1
Referring Physician Information

2
Hospital / Treating
Center Information

3
Administering Provider
Information

4
Site Coordinator Information

(what's this?)

5
Patient Information


6
Patient Primary
Insurance Information

7
Patient Secondary
Insurance Information

8
Patient Diagnosis
Primary Diagnosis

Secondary Diagnosis

9
Mapping and Treatment
Mapping & Treatment should not be performed until insurance authorization has been received



(what's this?)

10
Pre-Treatment
Evaluation Codes
Mapping
Imaging

Pre Y90 Treatment

SIR-Spheres® Y-90 Microspheres HCPCS Codes



11
Microspheres
Administration Codes
Authorized User (AU) Codes

Interventional Radiology (IR) Codes

Post-Treatment Imaging




What's this?


File Attachments







(on the next page you will be able to upload documents)



SIR-Spheres® is a registered trademark of Sirtex SIR-Spheres Pty Ltd.

Online pre-determination form
APM-US-374 V1 0320