Fillable PAIN MANAGEMENT NEUROABLATION AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan)

Fill Online, Printable, Fillable, Blank PAIN MANAGEMENT NEUROABLATION AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan) Form

Use Fill to complete blank online BLUE CROSS BLUE SHIELD OF MICHIGAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PAIN MANAGEMENT NEUROABLATION AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan)

On average this form takes 31 minutes to complete

The PAIN MANAGEMENT NEUROABLATION AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan) form is 4 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 119 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Blue Cross Blue Shield of Michigan forms online.

BROWSE BLUE CROSS BLUE SHIELD OF MICHIGAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PAIN MANAGEMENT
NEUROABLATION
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
NEUROABLATION
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 cervical/thoracic or
lumbar thermal
radiofrequency ablation
(answer a – i)
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. Are any radiculopathy or claudication symptoms (burning, tingling,
cramping) present?
Yes No
c. Are more than 2 levels (either unilateral or bilateral) planned for the
procedure?
Yes No
d. Has conservative treatment been attempted for at least 12 weeks/3
months?
Yes No
e. Has medication been attempted as part of conservative treatment? Yes No
f. Has chiropractic care, physical therapy, and/or home exercise program
been attempted as part of conservative treatment?
Yes No
g. Does imaging show any other possible causes of pain (such as stenosis,
nerve impingement, fracture, or infection)?
Yes No
h. Were two medial branch blocks performed at the same location as
planned radiofrequency ablation?
Yes No
i. Does the medical record show that BOTH medial branch blocks resulted
in at least 80% reduction in pain and improvement in function?
Yes No
Repeat cervical/thoracic or
lumbar thermal
radiofrequency ablation
(answer a – d)
a. Were criteria met for initial ablation? Yes No
b. Does the medical record confirm at least 50% reduction in pain and
improvement in function for at least 6 months after the prior procedure?
Yes No
c. Have 2 or more radiofrequency ablation sessions been done in this same
spine region in the past 12 months (cervical/thoracic or lumbar/sacral)?
Yes No
d. Have 4 or more total medial branch block sessions for the entire spine
been done in the past 12 months?
Yes No
PAIN MANAGEMENT
NEUROABLATION
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
Initial sacroiliac thermal
radiofrequency ablation
(answer a – f)
a. Is there presence of moderate to severe pain (rated at least 3 out of 10)
that interferes with daily activities?
Yes No
b. Has conservative treatment been attempted for at least
12 weeks/3 months?
Yes No
c. Has medication been attempted as part of conservative treatment? Yes No
d. Has chiropractic care, physical therapy, and/or home exercise program
been attempted as part of conservative treatment?
Yes No
e. Were 2 diagnostic injections performed on the L5 primary dorsal ramus
and the 1
st
– 3
rd
sacral dorsal rami branches?
Yes No
f. Does the medical record show at least 75% reduction in pain and
improvement in function with both diagnostic injections?
Yes No
Repeat sacroiliac thermal
radiofrequency ablation
(answer a – c)
a. Does the medical record confirm at least 50% reduction in pain and
improvement in function for at least 6 months after the prior procedure?
Yes No
b. Have 2 or more radiofrequency ablation sessions been done in this same
spine region in the past 12 months (cervical/thoracic or lumbar/sacral)?
Yes No
c. Have 4 or more total medial branch block sessions for the entire spine
been done in the past 12 months?
Yes No
Intraosseous
radiofrequency ablation
(basivertebral nerve)
No questions related to this procedure; proceed to next section.
Pulsed radiofrequency
ablation
No questions related to this procedure; proceed to next section.
Cooled radiofrequency
ablation
No questions related to this procedure; proceed to next section.
Endoscopic radiofrequency
ablation
No questions related to this procedure; proceed to next section.
Chemical ablation No questions related to this procedure; proceed to next section.
Laser ablation No questions related to this procedure; proceed to next section.
Cryoablation,
cryoanalgesia, or
cryoneurolysis
No questions related to this procedure; proceed to next section.
Procedure planned for any
area other than the spine
No questions related to this procedure; proceed to next section.
Do any of the following apply? (Answer a – d)
a. Systemic or localized infection at planned injection site Yes No
b. Radiofrequency ablation is planned at a fused spine level Yes No
c. Other pain management interventions planned same day (i.e. epidural steroid injection, SI joint injection,
trigger point injection, etc.)
Yes No
d. 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
PAIN MANAGEMENT
NEUROABLATION
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 4 | Page
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.
Form completed by:
Date:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PAIN MANAGEMENT NEUROABLATION AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 24 November 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document