Fillable PAIN MANAGEMENT FACET JOINT INJECTIONS AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan)

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PAIN MANAGEMENT FACET JOINT INJECTIONS AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan)

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PAIN MANAGEMENT
FACET JOINT INJECTIONS
AUTHORIZATION REQUEST FORM
Utilization management toll-free phone: 1-833-217-9670
Utilization management local phone: 313-908-6040
Utilization management fax: 313-483-7323
Revised July 2021 1 | Page
Today’s date (mm/dd/yyyy): ___ / ___ / _____
Member name:
Provider contact name:
Date of birth (mm/dd/yyyy): ___ / ___ / _____
Provider contact phone:
Member ID (including any alpha prefix):
Provider contact fax:
Health plan:
Provider name:
Notification method preference:
Postal mail
Fax
Provider TIN:
Mailing address or fax number:
Provider NPI:
Practice/group name:
Notes:
Provider physical address:
Provider mailing address (if different):
Where will the procedure take place?
Provider office Outpatient facility Inpatient hospital Ambulatory surgical center
Facility name:
Facility contact name:
Facility TIN:
Facility contact phone:
Facility NPI:
Facility contact fax:
Facility physical address:
Facility mailing address (if different):
PAIN MANAGEMENT
FACET JOINT INJECTIONS
AUTHORIZATION REQUEST FORM
Utilization management toll-free phone: 1-833-217-9670
Utilization management local phone: 313-908-6040
Utilization management fax: 313-483-7323
Revised July 2021 2 | Page
Requested procedure code Modifier: LT, RT or 50 (bilateral) Quantity Spine level
Diagnosis code(s):
Anticipated date of service (mm/dd/yyyy):
___ / ___ / _____
Patient’s height: Patient’s weight: Patient’s BMI:
What type of procedure is planned? (Select one and answer all adjacent questions.)
Initial medial branch
block
(answer a – j)
a. Has moderate to severe pain (rated at least 3 out of 10), primarily axial in
nature, been present for 3 months?
Yes No
b. Does the pain interfere with daily activities and get worse with bending or
twisting?
Yes No
c. Are any radiculopathy or claudication symptoms (burning, tingling, cramping)
present?
Yes No
d. Is the injection being done for diagnostic purposes only? Yes No
e. Will more than the recommended amount of anesthetic be used? (Total amount
less than 0.3cc for cervical spine and 0.5cc for lumbar)
Yes No
f. Are more than 2 levels (either unilateral or bilateral) planned for the procedure? Yes No
g. Has conservative treatment been attempted for at least 4 weeks/1 month? Yes No
h. Has medication been attempted as part of conservative treatment? Yes No
i. Has chiropractic care, physical therapy, and/or home exercise program been
attempted as part of conservative treatment?
Yes No
j. Does imaging show any other possible causes of pain (such as stenosis, nerve
impingement, fracture, or infection)?
Yes No
Second medial branch
block (i.e. facet joint(s)
that received one
block prior) (answer a –
d)
a. Were criteria met for initial block? Yes No
b. Does the medical record show at least 80% reduction in pain and improvement
in function with initial block?
Yes No
c. Have 4 or more medial branch block sessions been done in this same spine
region in the past 12 months (cervical/thoracic or lumbar)?
Yes No
d. Have 8 or more total medial branch block sessions for the entire spine been
done in the past 12 months?
Yes No
Third or greater medial
branch block (i.e. facet
joint(s) that received 2
or more blocks prior)
No questions related to this procedure; proceed to next section.
Initial therapeutic joint
injection for treatment
of facet cyst
(answer a – b)
a. Does imaging (CT, MRI) confirm facet cyst causing nerve root compression or
displacement?
Yes No
b. Does imaging correlate with symptoms and rule other possible causes out? Yes No
PAIN MANAGEMENT
FACET JOINT INJECTIONS
AUTHORIZATION REQUEST FORM
Utilization management toll-free phone: 1-833-217-9670
Utilization management local phone: 313-908-6040
Utilization management fax: 313-483-7323
Revised July 2021 3 | Page
Second therapeutic
joint injection for
treatment of facet cyst
(answer a – b)
a. Did the original symptoms return? Yes No
b. Does the medical record confirm at least 50% reduction in pain and
improvement in function after the first procedure?
Yes No
Third or greater joint
injection for treatment
of facet cyst
No questions related to this procedure; proceed to next section.
Initial therapeutic
injection for chronic
facet-related pain
(answer a – d)
a. Were two medial branch blocks performed at the same location as the planned
therapeutic intervention?
Yes No
b. Does the medical record show that BOTH medial branch blocks resulted in at
least 80% reduction in pain and improvement in function?
Yes No
c. Are more than 2 levels (either unilateral or bilateral) planned for the procedure? Yes No
d. Does the medical record document why a radiofrequency ablation is not
possible?
Yes No
Second or greater
therapeutic injection
for chronic facet-
related pain (i.e. facet
joint(s) that received at
least one therapeutic
injection prior)
(answer a – e)
a. Were criteria met for initial therapeutic injection? Yes
No
b. Are more than 2 levels (either unilateral or bilateral) planned for the procedure? Yes No
c. Does the medical record confirm at least 50% reduction in pain and
improvement in function for 3 months after the prior procedure?
Yes No
d. Have 4 or more therapeutic facet joint injection sessions been done in this
same spine region in the past 12 months (cervical/thoracic or lumbar)?
Yes No
e. Have 8 or more total therapeutic facet joint injection sessions for the entire
spine been done in the past 12 months?
Yes No
Do any of the following apply? (Answer a – f)
a. Injection with steroid planned with uncontrolled diabetes, uncontrolled hypertension, or congestive heart
failure present
Yes No
b. Systemic or localized infection at planned injection site Yes No
c. Facet joint intervention is planned at a fused spine level Yes No
d. Facet joint intervention is planned at the site of a previously successful radiofrequency ablation Yes No
e. Other pain management interventions planned same day (i.e. epidural steroid injection, SI joint injection,
trigger point injection, etc.)
Yes No
f. Pain management procedures planned in multiple regions (i.e. cervical/thoracic AND lumbar or sacral) Yes No
Will the procedure be performed with fluoroscopic guidance? Yes No
Is general anesthesia, conscious sedation, or monitored anesthesia care planned? Yes No
Include imaging reports, surgical plan and clinical documentation of all conservative therapies that have been attempted as well as
the duration of each type of conservative treatment.
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PAIN MANAGEMENT FACET JOINT INJECTIONS AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan)

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Completed 24 November 2021

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