Prior Authorization Request (Lumbar Fusion)

Document Title: Prior Authorization Request – Lumbar Fusion

Request Status: [initial / resubmission / appeal]

Date Authored: [Date]

Requested Date of Service: [Date]

Requesting Provider: [Name, credentials, NPI, contact phone/fax]

Facility: [Name]; [inpatient / outpatient / ASC]

Payer/Plan: [Payer name]; [Plan type]; [Member ID]; [Group ID if known]

Patient: [Name]; [DOB]; [MRN]

Requested Procedure

• Procedure (plain language): [Procedure description]
• Levels to be fused: [Specific lumbar levels]
• Approach: [posterior / anterior / lateral]; [open / minimally invasive]
• CPT codes: [Codes with descriptions / pending coder review]
• ICD-10 codes: [Codes with descriptions / pending coder review]
• Primary indication category: [degenerative spondylolisthesis with stenosis or instability / isthmic spondylolisthesis or pars defect / iatrogenic or anticipated instability from decompression / degenerative deformity / revision for pseudarthrosis / recurrent herniation with instability / tumor or infection or trauma]

Medical Necessity Summary

(Limit to 8–12 bullets with concrete numbers, dates, and measurements. Follow the order below.)

• Primary diagnosis and symptomatic level(s): [Diagnosis] at [level(s)]
• Key symptoms and duration: [axial / radicular / neurogenic claudication] pattern; total duration [weeks/months/years]
• Functional impairment: [Walking tolerance in minutes or distance]; [work status]; [ADL limitations]; [ODI score and date if available]
• Neurologic findings: [Specific deficits with myotome/dermatome/reflex grading / no focal neurologic deficit]
• Imaging concordance: [Study type] on [date] shows [one-line key finding] correlating with [symptom distribution or exam]
• Instability evidence: [Slip level and grade]; [dynamic translation in mm and/or angulation in degrees on flex/ext]; [facet effusion or synovial cyst if used as surrogate / not demonstrated]
• Conservative care summary: [Total duration]; [modalities tried with specifics]; [outcome]
• Rationale for fusion vs decompression alone or continued conservative care: [Why fusion is required and alternatives are inadequate]
• Urgency: [routine / expedited]; [red flags present / no red flags] (If expedited, include objective justification.)

Clinical Presentation

[Narrative of symptom onset and duration; dominant pattern and distribution; aggravating and relieving factors; trajectory over time; current functional limitations] (5–8 sentences; include only explicitly documented details.)

• Pain severity (0–10): Current [score]; Average [score]; Worst [score]
• Walking/standing tolerance: [Tolerances]; [assistive device use if any]
• Work status: [working full duty / modified duty / on leave / disabled / not applicable]; [relevant dates]
• Red flags: Bowel/bladder changes [present / absent]; Saddle anesthesia [present / absent]; Progressive weakness [present / absent]

Relevant History

(Include only information that impacts surgical indication, risk, or payer criteria.)

• Prior spine procedures: [Procedure type, levels, dates, outcomes / none]
• Fusion risk factors: Osteoporosis status [status and T-score if known]; Diabetes [A1c and date if applicable]; Nicotine [current / former / never; date of last use if applicable]; BMI [value]
• Optimization plan: [Cessation program, bone health evaluation, glycemic plan as applicable / not applicable]

Physical Examination

• Gait: [normal / antalgic]; heel walk [intact / impaired]; toe walk [intact / impaired]
• Lumbar spine: ROM [description]; tenderness [present with location / absent]
• Motor strength (0–5 scale): [Findings by myotome bilaterally]
• Sensation: [Dermatomal findings]
• Reflexes: Patellar [grade and symmetry]; Achilles [grade and symmetry]
• Provocative tests: SLR [positive / negative, side]; Femoral stretch [positive / negative, side / not tested]
• Claudication screen: [Findings if applicable / not applicable]

(If exam is normal, document explicitly: Motor 5/5 all myotomes; sensation intact; reflexes symmetric 2+.)

Imaging Findings

(Create a sub-block for each relevant study. For multi-level fusion, each level must have supporting documentation.)

[Study type] – [Date] – [Facility]

• Key findings: [Concise summary of pathology]
• Instability details: [Slip level and grade or percent]; [Dynamic translation in mm]; [Dynamic angulation in degrees]; [fixed / mobile]; [Surrogate markers if applicable / not applicable]
• Clinical correlation: [One line explaining concordance with symptoms and exam]

[Additional study type] – [Date] – [Facility]

• Key findings: [Summary]
• Instability details: [Details if applicable]
• Clinical correlation: [Concordance statement]

(Add additional study blocks as needed. Use surgeon's measurements if radiology report lacks quantification.)

Conservative Management Timeline

(List chronologically with auditable detail: type, date range, provider/setting, dosage or frequency, response with quantified outcomes, reason discontinued.)

• Physical therapy: [Date range]; [number of sessions]; [setting/provider]; [focus]; [response]; [reason stopped]
• Medications: [NSAIDs with name, dose, duration, response]; [Neuropathic agents with name, dose, duration, response]; [Other medications]
• Injections: [Type]; [level]; [date(s)]; [percent and duration of relief]
• Activity modification/bracing: [Date range]; [specifics]; [response]
• Other modalities: [Type]; [dates]; [response]

Exception justification (if conservative care bypassed or abbreviated): [Objective reason with dates and supporting findings] (Include only if applicable.)

Assessment and Level-by-Level Rationale

Primary surgical indication: [Statement of indication]

[Level]

• Pathology: [Specific imaging finding at this level]
• Symptom/exam correlation: [Distribution and corresponding findings]
• Why fusion required: [instability / pars defect / anticipated iatrogenic instability / revision for pseudarthrosis / other]

[Additional level]

• Pathology: [Findings]
• Symptom/exam correlation: [Correlation]
• Why fusion required: [Rationale]

(Add level-specific blocks for each fused level. Include differential considerations only if symptoms are atypical or imaging is discordant.)

Plan and Alternatives

[Proposed procedure with approach and instrumentation intent]. [Why continued conservative care is inadequate]. [Why decompression alone is insufficient]. [Expected goals: pain reduction targets, functional improvement, neurologic protection]. [Consequences of non-approval or delay: progression risk, ongoing disability, neurologic deterioration potential].

Shared Decision-Making

[Attestation that patient participated in decision-making; risks, benefits, and alternatives including nonoperative options were discussed; expected outcomes and uncertainties were reviewed; patient preference is to proceed with surgery]. (For revision or higher-risk cases, document counseling regarding variable outcomes and fusion success rates.)

Supporting Documentation

• Imaging reports (MRI, CT, X-ray including flexion-extension): [attached / unavailable: reason]
• PT evaluation and discharge summaries: [attached / unavailable: reason]
• Injection procedure notes with follow-up response: [attached / unavailable: reason / not applicable]
• Prior operative reports: [attached / unavailable: reason / not applicable]
• PROM scores (ODI): [attached / unavailable / not collected]
• Clinic notes documenting neurologic findings or progression: [attached / unavailable: reason]

Signature

Provider Signature: [Signature]

Printed Name and Credentials: [Name, degrees]

Date/Time: [Date and time]

Peer-to-Peer Contact: [Direct phone and availability]

(This is a payer-facing prior authorization template. Use specific dates, durations, measurements, and quantifiable outcomes throughout. Do not infer conservative care participation, imaging findings, or neurologic deficits—mark as unavailable if not documented. Omit sections with no relevant content rather than leaving empty placeholders, but always address red flags explicitly as present or absent. If a payer criterion is not met but surgery is indicated, include explicit exception justification explaining why delay increases risk.)