ࡱ> ?B>  bjbj 3 8?[(&4ooooo%%%%%%%\(*d%%oo%!!!|oo%!%!!:",K#o%p" %%0(&"Rb+b+K#K#b+_#X!%%!(&b+ :  Pre-Certification Request Date: ________________ T0:__________________ From: _______________ RE: Precertification for Thyroid Cancer Management ________________________________________________________________________ _________________________ is under the care of Dr___________________ for the treatment of thyroid cancer. The patient is being prepared to undergo a coordinated set of diagnostic procedures requiring authorizations for laboratory testing and nuclear medicine procedures. A copy of the schedule for these procedures follows. Relevant CPT codes are: TSH: 84443 hCG :84703 (for women of child-bearing potential) Thyroglobulin: 84432 Radioiodine dosing: 78018 Radioiodine scanning: 78006 Radioiodine treatment: 79005 Please fax (_____-____-_____) or call (____-____-____) to authorize performance of these procedures. 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