REVIEW REQUEST FOR
Percutaneous Neurolysis for Chronic Back Pain
Provider Data Collection Tool Based on Medical Policy SURG.00066
Policy Last Review Date: 11/18/2010
Policy Effective Date: 01/12/2011
Provider Tool Effective Date: 01/12/2011
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:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the individual:
Request is for (Check all that apply)
Initial radiofrequency (RF) neurolysis
Repeat radiofrequency neurolysis at the same anatomic site (side and spinal level)
Date of last neurolysis:
Chemical neurolysis
Pulsed radiofrequency neurolysis
Laser neurolysis
Cryodenervation (cryoablation)
Individual has following conditions (Check all that apply)
Cervical facet pain (C2-C3 thru C7-T1 vertebrae)
Lumbosacral facet pain (T12-L1 thru L5-S1 vertebrae)
Sacroiliac (SI) joint pain
Thoracic facet pain
Other: (please list)
Check all of the following criteria that apply:
Individual has had no prior spinal fusion surgery in the vertebral level being treated
Individual has pain which is not radicular
Individual has low back (lumbosacral) or neck (cervical) pain suggesting facet joint origin when evidenced by the
absence of nerve root compression and is documented in medical records on history, physical evaluation, and
radiographic evaluation
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REVIEW REQUEST FOR
Percutaneous Neurolysis for Chronic Back Pain
Provider Data Collection Tool Based on Medical Policy SURG.00066
Policy Last Review Date: 11/18/2010
Policy Effective Date: 01/12/2011
Provider Tool Effective Date: 01/12/2011
Individual has pain that has failed to respond to three (3) months of conservative management (e.g.,
physical/chiropractic therapy, oral medication, activity modification) and is documented in the medical record
A diagnostic, temporary block with local anesthetic of the facet nerve (medial branch block) or injection under
fluoroscopic guidance into the facet joint has resulted in at least a 50% reduction in pain for the duration of the
specific local anesthetic effect used [e.g. generally 3-4 hours for bupivacaine (Marcaine® , Sensorcaine® ) and 30
minutes to 1 hour for lidocaine (Xylocaine® )];
Other: (please list)
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 Anthem 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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