REVIEW REQUEST FOR
Cervical Fusion
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-42
Policy Last Review Date: 05/07/2015
Policy Effective Date: 07/07/2015
Provider Tool Effective Date: 11/01/2014
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):
Diagnosis Code(s) (if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Requested Procedure Codes (if applicable):
This request submission tool is for Anterior and Posterior Cervical Fusion (also
referred to as cervical spine fusion or spinal arthrodesis)
Please check all of the following that apply to the individual.
1.
Request is for treatment of neck pain in the absence of radiculopathy or myelopathy
Request is for treatment of referred pain in the absence of radiculopathy or
Myelopathy (for example, headache)
2.
Request is for treatment of documented symptomatic cervical radiculopathy. (Please check
all of the following that apply)
The individual has a profound neurologic deficit at initial presentation
The individual has progressive numbness or weakness
The individual has unremitting radicular pain
The individual has had no symptom improvement after at least 6 weeks of appropriate conservative
therapy (for example, nonsteroidal anti-inflammatory drugs [NSAIDs], oral corticosteroids,
physical therapy)
Imaging studies document nerve root compression (for example, computed
tomography [CT] with myelogram or magnetic resonance imaging [MRI]).
3.
Request is for treatment of symptomatic cervical pseudarthrosis. (Please check all of the
following that apply)
The presence of hardware failure or at least 6 months have passed since the initial fusion
Imaging studies (for example, CT, x-ray) document the pseudarthrosis
There are persistent symptoms (for example, pain) despite appropriate conservative management
4.
Request is for treatment of symptomatic single level or multilevel spondylotic myelopathy,
with or without kyphosis. (Please check all of the following that apply)
The individual has corresponding clinical symptoms (for example, bowel or bladder incontinence,
gait abnormality, frequent falls) and objective neurologic signs* (for example, hyperreflexia,
Lhermitte's sign, Hoffman sign, increased tone or spasticity of the lower or upper extremities)
(*Note: Long tract signs such as hyperreflexia may be absent in those with diabetes)
Imaging studies (for example, CT [with or without myelogram], MRI, x-ray) document cord
compression due to: (Please check all of the following that apply)
Herniated nucleus pulposus
Osteophyte formation
5.
Request is for treatment of symptomatic nontraumatic cervical spondylosis with instability.
(Please check all of the following that apply)
Radiographic findings document sagittal plane angulation of greater than 11 degrees between
adjacent segments
Radiographic findings document subluxation or translation of greater than 3.5 millimeters (mm) on
static lateral views or dynamic radiographs
6.
Request is for treatment of degenerative cervical kyphosis with spondylosis causing cord
compression
7.
Request is for treatment of degenerative spinal segment that is adjacent to prior
decompression or fusion procedure. (Please check all of the following that apply)
The symptomatic myelopathy corresponds clinically to adjacent level
The symptomatic radiculopathy corresponds clinically to adjacent level and is unresponsive to
nonoperative therapy
8.
Request is for treatment of infection of the cervical spine requiring decompression
Request is for treatment of infection of the cervical spine requiring debridement
(If either of the above is checked, please check the following if it applies)
The vertebral body destruction or abscess is documented by an imaging study (for example, MRI)
9.
Request is for treatment of nontraumatic atlantoaxial (C1-C2) instability
Request is for treatment of nontraumatic atlantoaxial (C1-C2) cord compression
(If either of the above is checked, please check all of the following that apply)
The Individual is diagnosed with a connective tissue disorder (for example, rheumatoid arthritis [RA])
The Individual is diagnosed with Down syndrome
The Individual is diagnosed with Os odontoideum
The Individual is diagnosed with skeletal dysplasia (for example, congenital abnormality of C1-C2)
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10.
Request is for treatment of nontraumatic atlantoaxial (C1-C2) subluxation
(If the above is checked, please check all of the following that apply)
Imaging studies [for example, MRI]) document the subluxation is greater than 5 mm .
The Individual is diagnosed with a connective tissue disorder (for example, rheumatoid arthritis [RA])
The Individual is diagnosed with Down syndrome
The Individual is diagnosed with Os odontoideum
The Individual is diagnosed with skeletal dysplasia (for example, congenital abnormality of C1-C2)
11.
Request is for treatment of posttraumatic cervical instability (for example, fracture,
subluxation/dislocation or major posterior ligamentous instability)
Imaging studies have been performed and document cervical instability
12.
Request is for treatment of ossification of the posterior longitudinal ligament (OPLL), with or
without kyphosis, associated with cervical stenosis and myelopathy
13.
Request is for treatment of spinal repair with fusion (for example, as part of a stabilization
procedure due to extensive surgery) performed in conjunction with other procedures (for example,
laminectomy) for abscess, dislocation, fracture, infection, neural decompression, or tumor
14.
Request is for treatment of tumor of the cervical spine (primary bone or metastatic tumor) causing
cord compression, instability, or pathologic fracture. (Please check all of the following that apply)
Imaging studies (for example, MRI) document the diagnosis of tumor
Excision of the lesion alone, without fusion, will result in further pathologic anatomy and symptoms
15.
Request is for treatment of deformity or progressive neck pain.
The individual has previously undergone a posterior cervical decompressive laminectomy
The individual has previously undergone a posterior cervical laminoplasty
16.
Request is for treatment of another condition not listed
Please describe the condition:
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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