Medical notes documenting the following, when applicable:

• Condition requiring procedure

• History and co-morbid medical condition(s)

• Smoking history/status, including date of last smoking cessation

• Member’s symptoms, pain, location, and severity including functional impairment that is interfering with activities of daily living (ADLs)

• Prior treatments tried, failed, or contraindicated; include the dates, duration, and reason for discontinuation

• Failure of conservative therapy through lack of clinically significant improvement between at least two measurements, on a validated pain or function scale or quantifiable symptoms despite concurrent conservative therapies

• Progressive deficits with clinically significant worsening based on at least two measurements over time

• Surgical history, including date(s) and outcome(s)

• Disabling symptoms

• Upon request, we may require the specific diagnostic image(s) that show the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of benefit to select the optimal images

  • Note: When requested, diagnostic image(s) must be labeled with:

    • The date taken

    • Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

  • Upon request, diagnostic imaging must be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be accepted

• Diagnostic image(s) report(s) by a radiologist, including presence or absence of:

  • Segment(s) instability

  • Spinal cord compression

  • Disc herniation

  • Nerve root compression

  • Quantification of subluxation, translation by flexion, angulation when appropriate

  • Discitis

  • Epidural abscess

  • Scoliosis

  • Kyphosis

• Physical exam, including neurologic exam and degree and progression of curvature (for scoliosis); include quantification of relevant muscle strength

• Whether the surgery will be performed with direct visualization or only with endoscopic visualization

• Complete report(s) of diagnostic tests, including:

  • Results of biopsy(ies)

  • Results of bone aspirate

• Describe the surgical technique(s) planned

• For revision surgery, include documentation of:

  • Clinical complications

  • Relevant laboratory findings

  • Relevant imaging

  • Prior treatments for complications tried, failed, or contraindicated; include the dates and reason for discontinuation