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:
CONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacy regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information is intended only for the use of the recipient (s) named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without saving them in any manner.
Page 1 of 4
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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
Page 3 of 4
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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:
Page 4 of 4
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
