Avera Health



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 & HCPCS 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 radiculopathy Lumbar radiculopathy

Low back pain Other:      

Symptoms (please check all that apply):

Cervical nerve root compression documented by EMG MRI nondiagnostic for etiology of pain

Cervical nerve root compression documented by MRI No neurologic symptoms or findings

Cervical nerve root compression documented by MYL-CT No neurologic symptoms or findings

Cervical nerve root compression documented by nerve conduction study Pain interferes with ADLs

Lumbar nerve root compression documented by CT Pain, mild to moderate

Lumbar nerve root compression documented by EMG Pain, refractory severe

Lumbar nerve root compression documented by MRI Pain unrelieved by change in body position

Lumbar nerve root compression documented by MYL-CT Unilateral pain in nerve root distribution

Lumbar nerve root compression documented by nerve conduction study Other:      

Previous Treatments (please check all that apply):

Activity modification for       weeks Opiate treatment contraindicated or not tolerated

NSAID therapy for       weeks Opiate treatment for       weeks

NSAID therapy contraindicated or not tolerated Physical therapy for       weeks

Other:      

Worsening pain after treatment? Yes No

Continued pain 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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Epidural Steroid Injection

Preauthorization Form

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