Avera Health

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Please complete this form completely. NOTE: For your patient to receive the lowest out-of-pocket costs, use in-network providers unless preauthorization is obtained from Avera Health Plans. Check the Avera Health Plans Provider Directory at . Decisions are based on eligibility, benefit determination and medical necessity.

Member’s name:       Member’s DOB:      

Member’s ID Number:       Group Number:      

ICD code(s), please list all that apply:      

CPT code(s), please list all that apply:      

Where will procedure take place?      

Date of procedure:       Procedure will be: outpatient inpatient

Conditions (please check all that apply):

Cervical disc herniation or foraminal stenosis Myelopathy

Lumbar disc herniation Other:      

Symptoms (please check all that apply):

Bilateral loss of dexterity Pain, paresthesias or numbness in shoulder

Bilateral lower extremity weakness, numbness or pain Severe myelopathy symptoms and findings

Bilateral upper extremity weakness, numbness or pain Severe weakness in a nerve root distribution by physical exam

Bladder dysfunction excluded Spasticity by physical exam

Bowel dysfunction excluded Spinal cord compression confirmed by MRI

Mild to moderate myelopathy symptoms and findings Spinal cord compression confirmed by MYL-CT

Mild to moderate weakness in a nerve root distribution by physical exam Unilateral radiculopathy with motor deficit

Nerve root compression confirmed by imaging Unilateral radiculopathy with sensory deficit

Other etiologies excluded Unsteady gait

Pain, paresthesias or numbness in a nerve root distribution Weakness in an extremity by physical exam

Pain, paresthesias or numbness in arm Worsening weakness or motor deficit

Pain, paresthesias or numbness in neck Other:      

Previous Treatments (please check all that apply):

Acetaminophen therapy for       weeks Activity modification for       weeks

NSAID therapy for       weeks Other:      

Home exercise or PT for       weeks

Did symptoms or findings continue after treatment? Yes No

Please Explain:      

Prescriber Name:       Today’s Date:      

Person completing the form:       Your Office/Facility Name:      

Your Phone Number: (       )       Your Fax Number: (       )      

IMPORTANT NOTICE: This determination does not guarantee benefits or payment of services. Payment of services is subject to patient eligibility at the time of treatment, benefit plan limitations and the other terms of the benefit plan. Payment of benefits is only made for services deemed medically necessary and appropriate. The final payment decision will be made upon submission of a claim by Avera Health Plans. If you have questions about your benefits, please contact Avera Health Plans Service Center at 605-322-4545 or toll-free at 1-888-322-2115. This form is not all-inclusive of services requiring preauthorizations. Refer to patient’s Certificate of Coverage or Summary Plan Document for more information.

Fax this completed form to Avera Health Plans at 1-800-269-8561 or send secure email to HealthServices@.

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Discectomy/Microdiscectomy

Preauthorization Form

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