REVIEW REQUEST FOR
Percutaneous Neurolysis for
Chronic Neck and Back Pain
Provider Data Collection Tool Based on Medical Policy SURG.00066
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
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:
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
This medical policy based data collection tool is for a medical necessity request for the use
of percutaneous surgical procedures (including Pulsed Radiofrequency (PRF) denervation,
lasers, cryodenervation, chemical neurolysis, and cooled radiofrequency denervation) for
the destruction of nerves (neurolysis) in individuals with chronic neck and back pain.
Please check all that apply to the individual:
SECTION I: INITIAL Procedure for single facet joint
□ The request is for initial radiofrequency (RF) neurolysis for chronic cervical facet pain (C2-C3
through C7-T1 vertebrae)
□ The request is for initial radiofrequency (RF) neurolysis for chronic lumbosacral facet pain (T12L1 through L5-S1 vertebrae)
(If EITHER of the above is checked, mark all of the following that apply to the individual)
□ No prior spinal fusion has been done in the vertebral level that is being treated
□ Pain is NOT radicular
□ Low back (lumbosacral) or neck (cervical) pain, suggests a facet joint origin as evidenced by the
absence of nerve root compression and is documented in the medical record on history, physical,
and radiographic evaluations
□ Pain has failed to respond to 3 months of conservative therapy*
REVIEW REQUEST FOR
Percutaneous Neurolysis for
Chronic Neck and Back Pain
Provider Data Collection Tool Based on Medical Policy SURG.00066
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
□ A diagnostic, temporary block with local anesthetic of the facet nerve (medial branch block) or an
injection under fluoroscopic guidance into the facet joint has been done
□ The diagnostic, temporary block or injection under fluoroscopic guidance resulted in at least a
50% pain reduction for the duration of the specific local anesthetic effect used [e.g., generally 34 hours for bupivacaine (Marcaine®, Sensorcaine®) and 30 minutes to 1 hour for lidocaine
(Xylocaine®)].
□ Additional facet levels are being requested for treatment.
Please specify level(s): _________________ (Proceed to SECTION III)
*Note: Conservative therapy consists of an appropriate combination of medication (for example,
NSAIDs, analgesics), in addition to, physical therapy, spinal manipulation therapy, cognitive
rehabilitation, or other interventions based on the individual's specific presentation, physical findings
and imaging results.
SECTION II: REPEAT Procedure for single facet joint
□ Request is for a repeat radiofrequency (RF) neurolysis for chronic cervical facet pain (C2-C3
through C7-T1 vertebrae)
□ Request is for a repeat radiofrequency (RF) neurolysis for chronic lumbosacral facet pain
(T12- L1 through L5-S1 vertebrae)
(If EITHER of the above is checked, mark all of the following that apply to the individual)
□ No prior spinal fusion has been done in the vertebral level that is being treated
□ Pain is NOT radicular
□ Low back (lumbosacral) or neck (cervical) pain, suggests facet joint origin as evidenced by the
absence of nerve root compression as documented in the medical record on history, physical, and
radiographic evaluations
□ Pain has failed to respond to 3 months of conservative therapy*
□ A minimum of 6 months has passed since prior RF treatment, per side, per anatomical level of the
spine
□ It has been less than 1 year since the last RF, and a diagnostic, temporary block with local
anesthetic of the facet nerve (medial branch block) or an injection under fluoroscopic guidance
into the facet joint has not been done
□ It has been 1 year or more since the last RF, and a diagnostic, temporary block with local
anesthetic of the facet nerve (medial branch block) or an injection under fluoroscopic guidance
into the facet joint has been done
□ The diagnostic, temporary block or injection under fluoroscopic guidance 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®)].
□ Additional facet levels are being requested for treatment.
Please specify level(s): _________________
(Proceed to SECTION IV)
REVIEW REQUEST FOR
Percutaneous Neurolysis for
Chronic Neck and Back Pain
Provider Data Collection Tool Based on Medical Policy SURG.00066
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
SECTION III – INITIAL REQUEST FOR ONE ADDITIONAL LEVEL
□ Request is for initial radiofrequency (RF) neurolysis at 1 additional level for chronic cervical
facet pain (C2-C3 through C7-T1 vertebrae) Specify level: _____________
□ Request is for initial radiofrequency (RF) neurolysis at 1 additional level for chronic lumbosacral
facet pain (T12-L1 through L5-S1 vertebrae) Specify level: _______________
(If EITHER of the above is checked, mark all of the following that apply to the individual)
□ No prior spinal fusion has been done in the vertebral level that is being treated
□ Pain is NOT radicular
□ Low back (lumbosacral) or neck (cervical) pain, suggests a facet joint origin as evidenced by
the absence of nerve root compression and is documented in the medical record on history,
physical, and radiographic evaluations
□ Pain has failed to respond to 3 months of conservative therapy*
□ A diagnostic, temporary block with local anesthetic of the facet nerve (medial branch block)
or an injection under fluoroscopic guidance into the facet joint has been done
□ The diagnostic, temporary block or injection under fluoroscopic guidance resulted in at least a
50% pain reduction 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®)].
□ An additional level is also being treated.
Please specify level(s): _________________ (Proceed to SECTION V)
SECTION IV – REPEAT PROCEDURE FOR ONE ADDITIONAL LEVEL
□ Request is for a repeat radiofrequency (RF) neurolysis at 1 additional level for chronic cervical
facet pain (C2-C3 through C7-T1 vertebrae) Specify level: ________________
□ Request is for a repeat radiofrequency (RF) neurolysis at 1 additional level for chronic
lumbosacral facet pain (T12- L1 through L5-S1 vertebrae) Specify level: ___________
(If EITHER of the above is checked, mark all of the following that apply to the individual)
□ No prior spinal fusion has been done in the vertebral level that is being treated
□ Pain is NOT radicular
□ Low back (lumbosacral) or neck (cervical) pain, suggests facet joint origin as evidenced by the
absence of nerve root compression as documented in the medical record on history, physical,
and radiographic evaluations
□ Pain has failed to respond to 3 months of conservative therapy*
□ A minimum of 6 months has passed since prior RF treatment, per side, per anatomical level of
the spine
□ It has been less than 1 year since the last RF,and a diagnostic, temporary block with local
anesthetic of the facet nerve (medial branch block) or an injection under fluoroscopic guidance
into the facet joint has not been done
□ It has been 1 year or more since the last RF , and a diagnostic, temporary block with local
anesthetic of the facet nerve (medial branch block) or an injection under fluoroscopic guidance
into the facet joint has been done
□ The diagnostic, temporary block or injection under fluoroscopic guidance 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®)].
□ An additional level is also being treated.
Please specify level(s); _______________ (Proceed to SECTION VI)
REVIEW REQUEST FOR
Percutaneous Neurolysis for
Chronic Neck and Back Pain
Provider Data Collection Tool Based on Medical Policy SURG.00066
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
SECTION V: INITIAL Procedure for more than one additional facet joint
□
Request is for initial radiofrequency (RF) neurolysis at more than one additional level for
chronic cervical facet pain (C2-C3 through C7-T1 vertebrae).
Specify additional level(s): ____________
□ Request is for initial radiofrequency (RF) neurolysis at more than one additional level for
chronic lumbosacral facet pain (T12-through L5-S1 vertebrae).
Specify additional level(s): __________
(If EITHER of the above is checked, mark all of the following that apply to the individual)
□ No prior spinal fusion has been done in the vertebral level that is being treated
□ Pain is NOT radicular
□ Low back (lumbosacral) or neck (cervical) pain, suggests a facet joint origin as evidenced by the
absence of nerve root compression and is documented in the medical record on history, physical,
and radiographic evaluations
□ Pain has failed to respond to 3 months of conservative therapy*
□ A diagnostic, temporary block with local anesthetic of the facet nerve (medial branch block) or an
injection under fluoroscopic guidance into the facet joint has been done
□ The diagnostic, temporary block or injection under fluoroscopic guidance resulted in at least
a 50% pain reduction 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®)].
SECTION VI – REPEAT PROCEDURE for more than one additional facet joint
□ Request is for a repeat radiofrequency (RF) neurolysis at more than 1 additional level for chronic
cervical facet pain (C2-C3 through C7-T1 vertebrae) . Specify additional level(s): ______________
□ Request is for a repeat radiofrequency (RF) neurolysis at more than 1 additional level for chronic
lumbosacral facet pain (T12- L1 through L5-S1 vertebrae). Specify additional level(s): _________
(If EITHER of the above is checked, mark all of the following that apply to the individual)
□ No prior spinal fusion has been done in the vertebral level that is being treated
□ Pain is NOT radicular
□ Low back (lumbosacral) or neck (cervical) pain, suggests facet joint origin as evidenced by the
absence of nerve root compression as documented in the medical record on history, physical, and
radiographic evaluations
□ Pain has failed to respond to 3 months of conservative therapy*
□ A minimum of 6 months has passed since prior RF treatment, per side, per anatomical level of the
spine
□ It has been less than 1 year since the last RF,and a diagnostic, temporary block with local
anesthetic of the facet nerve (medial branch block) or an injection under fluoroscopic guidance into
the facet joint has not been done
□ It has been 1 year or more since the last RF , and a diagnostic, temporary block with local
anesthetic of the facet nerve (medial branch block) or an injection under fluoroscopic guidance into
the facet joint has been done
□ The diagnostic, temporary block or injection under fluoroscopic guidance 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®)].
REVIEW REQUEST FOR
Percutaneous Neurolysis for
Chronic Neck and Back Pain
Provider Data Collection Tool Based on Medical Policy SURG.00066
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
SECTION VII
□ Request is for radiofrequency neurolysis for the treatment of cervicogenic headache or thoracic
facet pain
□ Request is for radiofrequency neurolysis for sacroiliac (SI) joint pain
□ Request is for chemical neurolysis for the treatment of chronic back pain, including but not limited to
facet or sacroiliac (SI) joint pain
□ Request is for pulsed radiofrequency denervation for the treatment of chronic back pain, including
but not limited to facet or sacroiliac joint pain
□ Request is for laser neurolysis for the treatment of chronic back pain, including but not limited to
facet or sacroiliac (SI) joint pain
□ Request is for cryodenervation (cryoablation) for the treatment of chronic back pain, including but
not limited to facet or sacroiliac (SI) joint pain
□ Request is for cooled radiofrequency denervation for the treatment of chronic back pain, including
but not limited to facet or sacroiliac (SI) joint pain
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.