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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
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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