REVIEW REQUEST FOR
Lumbar Laminectomy, Hemi-Laminectomy,
Laminotomy and/or Discectomy
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-38
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 08/18/2014
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Service Requested (CPT if known):
Place of Service:
Home
Outpatient
Other:
Inpatient
Diagnosis Code(s) (if known):
This data collection tool is for provider medical necessity review request for lumbar
laminectomy, hemilaminectomy, laminotomy (for unilateral symptoms), and/or discectomy
(using an open approach with direct visualization) as a means to surgically manage various
lumbar conditions.
IMPORTANT: A current dated MRI report must be submitted along with this form,
completed in its entirety to facilitate your requested review. Also please submit all other
radiological reports and test results (for example, X-ray, CT and EMG, etc.)
SECTION I
□ Individual has had previous spine surgery
Specify dates and levels of prior surgery: ___________________________________
□ Request is for InPatient service (If checked, answer the following)
Please specify the number of inpatient days requested: ___________________
Please specify individual’s comorbid conditions, if any: _____________________
□ Request is for OutPatient service
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REVIEW REQUEST FOR
Lumbar Laminectomy, Hemi-Laminectomy,
Laminotomy and/or Discectomy
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-38
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 08/18/2014
SECTION II
□ Request is for lumbar laminectomy(If checked, specify the level(s)and specific side(s)below)
□ L1-L2 □ L2-L3 □ L3-L4 □ L4-L5 □ L5-S1□ Left □ Right □ Left & Right
□ Request is for lumbar hemilaminectomy (If checked, specify the level(s) and specific side(s)
below)
□ L1-L2 □ L2-L3 □ L3-L4 □ L4-L5 □ L5-S1□ Left □ Right □ Left & Right
□ Request is for lumbar laminotomy (for unilateral symptoms) (If checked, specify the level(s)
andspecific side(s) below)
□ L1-L2 □ L2-L3 □ L3-L4 □ L4-L5 □ L5-S1□ Left □ Right □ Left & Right
□ Request is for lumbar discectomy (If checked, specify the level(s) and specific side(s)below)
□ L1-L2 □ L2-L3 □ L3-L4 □ L4-L5 □ L5-S1□ Left □ Right □ Left & Right
□ Other surgical procedure(s) not listed above: Please specify: _____________________________
____________________________________________________________________________________
(If any of the above are checked, mark all of the following that apply to the individual:
□ Individual has conus medullaris syndrome (spinal cord compression)confirmed by appropriate
imaging studies (If checked, mark the following if it applies to the individual)
□ Individual has severe or progressive neurologic deficits (for example, fecal or urinary
incontinence)
□ Individual has cauda equina syndrome
(If checked, mark the following if it applies to the individual)
□ Individual has neurologic deficits (bowel or bladder dysfunction, saddle anesthesia, bilateral
neurologic abnormalities of the lower extremities)
□ Condition is confirmed by physical examination
□ Condition is confirmed by appropriate imaging studies
□ Individual has lumbar spinal stenosis and/or foraminal stenosisconfirmed by appropriate imaging
Studies. (If checked, mark the following if it applies to the individual)
□ Individual has severe and progressive symptoms of pain or neurogenic claudication (buttock or
leg)
□ The condition has been unresponsive to at least 6 weeks of conservative nonoperative therapy*
(See definition below) (If checked, provide the following information)
State the specific conservative treatment(s) received, with corresponding treatment
duration and dates: __________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
□ Individual has a significant motor deficit preventing ambulation
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REVIEW REQUEST FOR
Lumbar Laminectomy, Hemi-Laminectomy,
Laminotomy and/or Discectomy
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-38
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 08/18/2014
□ Individual has a lumbar herniated intervertebral disc with nerve root compressionconfirmed by
appropriate imaging studies(If checked, mark the following if it applies to the individual)
□ Individual has radicular pain with physical findings of nerve compression (for example, absent
lower extremity reflex or loss of sensation in dermatomal distribution)
□ Individual has alternative clinical findings consistent with radiculopathy
□ All other reasonable sources of pain have been ruled out
□ Findings on imaging correspond to the clinical findings and neurological examination
□ Symptoms are interfering with functional activities of daily living
□ Symptoms persist despite at least 6 weeks of conservative nonoperative therapy* (See
definition below) (If checked, provide the following information)
State the specific conservative treatment(s) received, with corresponding treatment
duration and dates: __________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
□ Symptoms are associated with significant or progressive motor deficits
□The procedure is to be performed with dorsal rhizotomy as a treatment for spasticity (for example,
cerebral palsy)
□
Individual has an acute fracture causing symptomatic nerve root compression
□
The procedure is to be performed with biopsy or excision. (If checked, mark the following if it applies
to the individual)
□ Signs or symptoms are indicative of lumbar disease (for example, pain, motorweakness)
□ Imaging suggests a tumor or metastatic neoplasm
□ Imaging suggests an infectious process (for example, epidural abscess)
□ Imaging suggests arteriovenous malformation
□ Imaging suggests a malignant or non-malignant mass
□ Other indication for the procedure that is not listed above.
Please specify the condition: ____________________________________
*Note to Provider: Conservative non-operative therapy consists of an appropriate combination of
medication (for example, Non-Steroidal Anti-Inflammatory Drugs [NSAIDs], analgesics), physical
therapy, spinal manipulation therapy, epidural steroid injections, or other interventions based on the
individual's specific presentation, physical findings and imaging results
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REVIEW REQUEST FOR
Lumbar Laminectomy, Hemi-Laminectomy,
Laminotomy and/or Discectomy
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-38
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 08/18/2014
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan
or its designees may perform a routine audit and request the medical documentation to verify the accuracy of the
information reported on this form.
Name and Title of Provider or Provider Representative Completing
Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be
accepted.
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs
utilization management services on behalf of your health benefit plan or the administrator of your health
benefit plan.
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