Prior Authorization Request (Cervical Fusion)

Request Type: [Initial / Re-review / Appeal] (If Appeal: include level - Level 1, Level 2, or External)

Submission Date: [Date]   Decision Timeframe: [Routine / Expedited] (If Expedited: briefly state reason)

Patient: Name: [Name]; DOB: [DOB]; Member ID: [ID]; Claim/Reference #: [Number / Unknown]

Requesting Clinician: Name: [Name]; Specialty: [Orthopedic Surgery (Spine) / Neurosurgery / PM&R - Interventional Spine / Other]; NPI: [NPI]; Phone: [Number]; Fax: [Number]; Best time for peer-to-peer: [Time window]

Servicing Facility: Name: [Facility]; Setting: [Inpatient / Outpatient / ASC]; Proposed surgery date: [Date / Pending]

Requested Procedure: [Plain language procedure description including approach and fusion/decompression type]; CPT: [Codes]; Levels: [e.g., C5-6, C6-7]; Primary ICD-10: [Codes]

(Use explicit status labels throughout: Unknown, Not done, Pending, or Not applicable where information is unavailable. Do not omit fields silently.)

Executive Medical Necessity Synopsis

[Concise 5–10 line summary linking indication → symptoms → objective deficits → imaging → conservative care status → why surgery is appropriate now] (Include: primary indication [radiculopathy / myelopathy / instability / revision]; symptom duration and trajectory; key functional limitations; key objective neurologic deficits; key imaging findings with modality and date; conservative management summary or exception with reason; and why the requested procedure and levels are indicated now.)

History of Present Illness

[Chief problem in one sentence stating main complaint and affected cervical levels if clinically evident]

• Onset and precipitating factors: [Onset date]; [Precipitating event / Gradual / Insidious]; [Prior injuries or surgeries relevant to current presentation]
• Pain and neurologic distribution: [Side]; [Dermatomal pattern]; [Paresthesias]; [Specific weakness by function, e.g., grip, wrist extension, triceps]; [Neck pain vs arm pain predominance]
• Myelopathic symptoms: [Hand dexterity issues / Buttoning / Handwriting changes]; [Balance / Gait disturbance]; [Falls]; [Bowel/bladder changes]; [None]
• Severity metrics: Pain score [0–10] (date: [Date]); [NDI % / mJOA score] (date: [Date]) (If not done, state "Not done")
• Course: [Stable / Worsening / Intermittent / Improving] (If progression documented: include dates and nature of change)

Functional Impact

• ADLs: [Dressing / Driving / Sleep / Computer work / Other] (Include at least 3 concrete limitations. If symptoms are not functionally limiting, state explicitly.)
• Work: [Job role]; [Work status: Full duty / Modified duty / Off work]; [Restrictions / Missed days]
• Safety risks: [Falls / Gait instability / Balance issues / None]

Relevant Comorbidities and Prior Cervical Procedures

• Secondary diagnoses affecting surgical decision-making: [e.g., diabetes, osteoporosis, inflammatory arthritis, OSA, nicotine use / None]
• Prior cervical procedures: [Procedure, levels, date, outcome, complications / None]
• Red flags: [Rapidly progressive weakness / Bowel-bladder changes / Falls / Severe gait impairment / None]

Conservative Management History

(Document each modality with type, dates, duration, frequency/adherence, provider/setting, clinical response with numeric change when possible, and reason stopped. If records unavailable, note request status.)

• Physical Therapy: [Start–end dates]; [Frequency]; [Adherence]; [Provider]; Response: [Pain/NDI change]; Stopped because: [Reason / Ongoing]; Records: [Attached / Requested from (facility) on (date) / Unknown]
• Medications: [NSAIDs / Neuropathic agents / Muscle relaxants / Opioids / Other] – [Drug, dose, duration]; Response: [Benefit / Side effects]; Status: [Stopped / Ongoing]
• Injections: [Epidural steroid injection / Facet / Medial branch block / Other]; Date: [Date]; Level: [Level]; Response: [Baseline vs post-injection pain; % improvement; duration of relief]; Complications: [None / Describe]
• Selective nerve root block: (Include only if performed and relevant to level selection) Date: [Date]; Level: [Level]; Baseline pain: [Score]; Post-block pain: [Score]; % improvement: [%]; Relief duration: [Duration]; Interpretation: [How it supports level selection]
• Other nonoperative care: [Activity modification / Bracing / Chiropractic / Acupuncture / Home exercise program / None] – [Details and response]
• Conservative care waiver: (Include only if conservative care is inappropriate or waived) [Myelopathy / Progressive motor weakness / Instability / Fracture / Infection / Tumor / Other] supported by: [Objective findings justifying waiver]
• Records status: [All attached / Partial – specify / PT notes requested from (facility) on (date) / Pending]

Physical Examination Findings

(Organize by domain; include side laterality and MRC grades. If documenting progression, compare explicitly to prior exam with date. If element not examined, document "Not examined.")

• Motor strength (MRC grade, L/R): C5 Deltoid: [Grade L/R]; C6 Wrist extensors: [Grade L/R]; C7 Triceps: [Grade L/R]; C8 Finger flexors: [Grade L/R]; T1 Interossei: [Grade L/R] (If compared to prior exam: [Date]: [Changes / Stable])
• Reflexes: Biceps (C5-6): [L/R]; Brachioradialis (C6): [L/R]; Triceps (C7): [L/R]; Asymmetry: [Yes – describe / No]
• Sensory: [Light touch / Pinprick] deficits in [Dermatomes, side]; [No deficits]
• Provocative tests: Spurling: [Positive – side / Negative / Not done]; Shoulder abduction sign: [Present / Absent / Not done]
• Myelopathy evaluation: Hoffmann: [Present / Absent / Not done]; Clonus: [Beats / Absent / Not done]; Babinski: [Upgoing / Downgoing / Not done]; Tone: [Increased / Normal]; Gait: [Normal / Wide-based / Antalgic / Spastic / Not examined]; Tandem gait: [Normal / Abnormal / Not examined]; Romberg: [Positive / Negative / Not examined]

Imaging and Diagnostic Correlation

(List each study with modality, date, facility, and key impressions. Provide level-by-level correlation tying imaging pathology to symptoms and objective deficits. Note and reconcile any discrepancy between surgeon interpretation and radiology report.)

• MRI Cervical Spine: Date: [Date]; Facility: [Facility]; Key findings: [Levels involved; foraminal stenosis severity; disc/osteophyte complex; canal stenosis; cord compression; T2 cord signal changes]
• CT Cervical Spine: Date: [Date]; Findings: [Ossification, osteophytes, foraminal encroachment, fusion status] (If not done: "Not done")
• X-rays: Date: [Date]; Views: [AP/lateral / Flexion-extension]; Findings: [Alignment; spondylolisthesis; dynamic instability; sagittal parameters] (If not done: "Not done")
• EMG/NCS: Date: [Date]; Conclusion: [Supports radiculopathy at (levels) / Normal / Non-diagnostic]; Relevance: [How it supports suspected root levels] (If not done: "Not done")

Level-by-Level Clinicoradiologic Correlation (Each requested surgical level requires its own justification.)

• [Level, e.g., C5-6]: Imaging: [Pathology and severity]; Symptoms: [Dermatomal pain/paresthesia distribution]; Objective: [Weakness/reflex/sensory findings]; Correlation: [Clear linkage / Partial – explain / Unclear – explain]
• [Level, e.g., C6-7]: Imaging: [Pathology and severity]; Symptoms: [Dermatomal pain/paresthesia distribution]; Objective: [Weakness/reflex/sensory findings]; Correlation: [Clear linkage / Partial – explain / Unclear – explain]
• Interpretation discrepancies: (Include only if surgeon interpretation differs from radiology report) [Discrepancy]; Resolution: [Consensus reached / Surgeon rationale]

Assessment

(Numbered problem list ordered by clinical severity. For each problem, include ICD-10 code, laterality, severity, and chronicity. Organize supporting evidence as Subjective, Objective, Imaging.)

1. [Problem name] (ICD-10: [Code]) – [Laterality/Level], [Severity], [Acute / Subacute / Chronic]
   • Subjective: [Key symptoms consistent with diagnosis]
   • Objective: [Exam deficits and/or EMG findings]
   • Imaging: [Findings at symptomatic level]
2. [Additional problem] (ICD-10: [Code]) – [Laterality/Level], [Severity], [Chronicity]
   • Subjective: [Details]
   • Objective: [Details]
   • Imaging: [Details]

Requested Procedure

• Procedure: [e.g., Anterior cervical discectomy and fusion (ACDF) / Posterior cervical decompression and fusion / Corpectomy and fusion]; Approach: [Anterior / Posterior]; Levels: [List]; Number of levels: [#]
• Why fusion is required: [Stability / Alignment restoration / Extent of decompression requiring structural support / Revision / Adjacent segment disease / Other – specify]
• Planned setting: [Inpatient / Outpatient / ASC]
• Why alternatives are not appropriate: [Continued nonoperative care: (reason inadequate)]; [Decompression alone: (instability risk or other reason)]; [Arthroplasty: (contraindication such as facet arthropathy, multilevel disease, deformity, osteoporosis)]

Medical Necessity Justification

[Narrative paragraph explicitly stating that the requested procedure is reasonable and necessary now based on: symptom severity and duration; objective neurologic deficits or validated functional impairment; imaging correlation at symptomatic levels; and failed adequate conservative management or documented exception.]

Criteria Mapping

• Symptoms consistent with diagnosis: [Yes / No] – [Supporting details]
• Objective neurologic deficit or qualifying substitute: [Yes / No] – [Motor/reflex/sensory/UMN signs or validated impairment score]
• Imaging confirms pathology at symptomatic level(s): [Yes / No] – [Modality, date, findings]
• Conservative management adequate and failed: [Yes / No] – [Duration, modalities, outcomes] (If waiver: [Reason with objective findings])
• Each requested level justified:
  • [Level]: [Specific rationale linking symptoms, objective deficits, and imaging]
  • [Level]: [Specific rationale linking symptoms, objective deficits, and imaging]
• Risk of delay: [Neurologic deterioration / Safety risks / Persistent disabling symptoms] – [Explanation]

Risk Optimization

(Include when payer-required or clinically relevant to authorization decision.)

• Nicotine/tobacco: [Never / Former / Current]; Cessation plan: [Plan / Not applicable]
• Diabetes: [Yes / No]; Most recent A1c: [Value] ([Date]); Optimization: [Plan / Not applicable]
• Osteoporosis: DXA: [Done – result / Pending / Not indicated]; Management: [Plan / Not applicable]
• BMI: [Value]; Considerations: [Risk discussion / Optimization steps / Not applicable]
• Other perioperative risks: [OSA / Anticoagulation / Malnutrition / None] – [Status and plan]

Closing

This prior authorization request is based on the patient's medical record. Supporting documentation is available upon request. Please contact for peer-to-peer review as needed at [Direct phone] during [Best times].

Attachments included: [Recent clinic note (date)]; [PT notes (date range)]; [Imaging reports (modalities, dates)]; [Injection procedure notes]; [EMG/NCS report]; [Other] (If items pending or unavailable, state status.)

Clinician Signature: [Name, credentials]   Date: [Date]