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Interventional Pain Management Request Clinical Worksheet

CT Other: Pain radiating into the Hand. Arm Shoulder Buttocks Elbow Leg Thigh: Foot. Knee Neck Chest Axial/localized pain in the: Upper/mid-back...

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Interventional Pain Management Request Clinical Worksheet

Ordering Provider

Patient/Member

For NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc. If there are any inconsistencies with the medical office records, please elaborate in the comment section. Failure to provide all relevant information may delay the determination. Phone and fax numbers can be found on eviCore.com under the Guidelines and Fax Forms section. You may also log into the provider portal located on the site to submit an authorization request. URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE.

First Name:

Middle Initial:

DOB (mm/dd/yyyy ):

Gender:

Street Address:

Facility/Site

Male

Female

Apt #:

City:

State:

Zip:

Home Phone:

Cell Phone:

Primary Contact:

Health Plan:

Member ID:

Group ID:

First Name: Primary Specialty:

Home

Cell

Last Name: TIN:

Physician Phone:

NPI: Physician Fax:

Address:

Suite #:

City:

State:

Zip:

Office Contact:

Ext:

Contact Email: First Name:

Last Name:

Group/Site Name: Primary Specialty:

TIN:

Site Phone:

NPI: Site Fax:

Address: City:

Diagnosis

Last Name:

Suite #: State:

Zip:

Diagnosis, if known or rule out: ICD-10 Codes: Auth/Reference Number (if continued care): Date of last visit:

Start date of this request:

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If this request is for Discography, Chemonucleosis, or Epidurography, do not use this worksheet. Procedure Code

Spinal Region (Cervical, Thoracic, Lumbar, Sacral, or N/A)

Level (i.e. C4-C5)

Side (Left, Right, Bilateral, or N/A)

Procedure

Primary Procedure: Procedure #2: Procedure #3: Procedure #4: Procedure #5: Procedure #6: Procedure #7: 1. Is this the first procedure of this type in this region (cervical/thoracic, lumbar/ sacral, extremity)?

Yes

No

2. Is there a posterior fusion at the level to be injected?

Yes

No

3. Has the member had any of the following? Herpes Zoster (HZ)

History of cancer with suspicion of bone metastases involving the spine

Unstable spinal fractures

Suspicion/known epidural abcess or discitis

Multiple sclerosis (MS)

Cauda Equina Syndrome

Clinical Information

None of the above 4. Indicate the member's imaging findings: Herniated disc

Vertebral mass/lesion

Annular tear

Foraminal Stenosis

Spinal Stenosis

Osteomyelitis

No abnormal findings

MRI has not been performed

Other:

5. If applicable, please indicate the guidance that will be used: Fluoroscopy

Ultrasound

CT

Other:

6. Does the patient present with any of the following symptoms or physical findings? Pain radiating into the Elbow

Leg

Axial/localized pain in the:

Thigh

Hand

Arm

Shoulder

Buttocks

Foot

Knee

Neck

Chest

Upper/mid-back

Lower back

Groin

Neck

Buttocks

Hip

Low back pain radiating to the groin on the same side as sacral pain

Loss of sensation and/or motor strength in affected nerve root distribution

Radiating pain in typical trigger point referral pattern

Absent/diminshed upper extremity (arm) and/or abdominal reflexes

Positive neural traction signs that reproduce sharp radiating pain

Absent/diminshed knee or ankle reflexes Page 2 of 4

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Axial/localized pain worse with upright posture

Pain around the sacroiliac joint

Axial/localized low back pain aggravated by positions causing joint compression

Positive physical test of sacroiliac joint dysfunction

Reduced range of motion

Spot tenderness

Pain along the spinal column

Muscle tenderness to palpation

Thoracic pain

Other:

7. On a scale from 0-10, what is the patient's most recent reported level of pain (based on the Visual Analog Scale)? 8. What is the date of onset of current pain symptoms? 9. What is the date the member began participation in conservative therapy? (Exercise, physical methods including physical therapy, chiropractic care, NSAID's and/or analgesics). 10. Please indicate all conservative therapy activities: Over the counter medication (ex: Tylenol, Aspirin)

Clinical Information

NSAIDs (Non-steroid anti-inflammatory drugs, ex: Advil, Aleve) Muscle relaxants (ex: Flexeril, Soma, Baclofen) Nerve stabilizers (ex: Topomax, Gabapentin (Neurontin), Tegretol) Antidepressants (ex: Cymbalta, Amitriptylline, Lyrica) Narcotics/Opioids (ex: Percocet, Vicodin, Oxycontin, Norco) Physical therapy strengthening program (ex: physical therapy, chiropractic care, acupuncture, massage therapy, rest/ice/heat, exercise, muscle stretching) No conservative therapy

Other:

11. What was the percent improvement in response to conservative treatment? 0-24%

25-49%

50-74%

75-100%

12. By how many points has pain decreased on the VAS?

Unknown 0

1

2

3+

13. If subsequent procedure, what was the percent improvement in response to the previous procedure? 0-24%

25-49%

50-74%

75-100%

14. If subsequent procedure, by how many points did pain decrease on the VAS in response to the previous procedure?

Unknown 0

1

2

3+

15. For ablation procedures, what method will be used? Thermal radiofrequency

Electrocautery

Cooled radiofrequency

None

Pulsed radiofrequency

16. How long did the improvement from the last ablation procedure last (in months)? 17. Is there co-management of behavioral health/medical conditions OR a plan to address potential opiate overuse or abuse?

Yes

No

N/A

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For trigger point injections (20552 and 20553), answer the additional questions below: 1. Which anatomical region(s)/muscle groups will be injected? Cervical

Thoracic

Upper extremity

Lower extremity

2. How many muscles will be injected?

1

2

Lumbar 3+

3. What medication will be injected? Select all that apply. Anesthetic

Prolotherapy

Steroid

Other:

Botulininum toxin

For anesthesia requests, answer the following questions. Note: If you plan to use Mac for this procedure, a separate request to determine medical necessity is required. 1. What procedure is the member having? Percutaneous disc decompression

Interlaminar epidural injection

Vertebroplasty

Implantation of a pump or pulse generator

Facet injection

Discogram

Percutaneous Lysis of epidural adhesions

Sacroiliac injection

Sympathetic blocks

Radiofrequency ablation of facet joints

Transforminal epidural injection

Other:

Clinical Information

2. Does the member have any of the following medical problems? Spasticity disorder making it difficult to lie still

Obesity with BMI >45

Inability to follow commands due to dementia or severe developmental delay

Uncontrolled Cardiopulmonary or systemic disease requiring constant presence of an anesthesiologist

Inability to complete prior attempts at injection therapy w/ conscious sedation

Severe sleep apnea (BIPAP required and home oxygen at night)

Other: 3. Is the physician performing the anesthesia servces also performing the pain management procedure?

Yes

No

4. What type of anesthesia will be provided? Minimum sedation

Moderate sedation

Deep sedation

5. Will the anesthesiologist be in attendance for the entire procedure?

General anesthesia Yes

No

Additonal Information/Comments:

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