Prior Authorization Request (Pain Procedure)

Prior Authorization Request – Pain Procedures

(Use MM/DD/YYYY for all dates. Use named, validated scales for pain and function. Provide objective, measurable statements with durations, adherence, percent relief, and quantified functional change. Avoid vague terms such as "failed PT" or "better.")

Patient Information

Patient name: [Patient full name]

DOB: [MM/DD/YYYY]

Member ID / Policy number: [Member ID / Policy number]

Insurance / Plan name: [Payer and plan name]

Provider Information

Facility name: [Facility name]

Facility address: [Street, City, State ZIP]

Facility NPI: [NPI]

Rendering clinician: [Name, Credentials]

Rendering clinician NPI: [NPI]

Referring clinician: [Name, Credentials, NPI] (Only include if different from rendering clinician)

Peer-to-peer contact: [Name, Title]

P2P phone: [Phone]

P2P fax: [Fax]

P2P availability: [Days/times and time zone]

Request Details

Request type: [initial / repeat] • [diagnostic / therapeutic] • [trial / permanent implant]

Requested date(s) of service: [MM/DD/YYYY or date range]

Expedited or standard: [expedited / standard] (If expedited, include specific reason tied to risk or loss of function)

Procedure and Coding

• Requested procedure name: [Plain language procedure name] — [Clinical terminology]
• CPT/HCPCS code(s) and units: [Code(s) with units]
• ICD-10-CM diagnosis code(s): [Code(s) with descriptions]
• Anatomical target: [Region] • [Laterality] • [Specific level(s)/joint(s)/nerve(s)]
• Imaging guidance planned: [fluoroscopy / CT / ultrasound] (Include contrast plan or documented contraindication)
• Setting: [office / ASC / HOPD]

Executive Summary

(This section provides a scannable overview for the medical director.)

• Diagnosis and Duration: [Primary pain diagnosis and pain generator] • [Onset date or total duration] • [Current episode start date]
• Baseline Status: [Pain score with named scale] • [Functional measure with score] • [Key ADL limitations quantified: walking tolerance, sitting/standing tolerance, sleep disruption, work restrictions]
• Conservative Care Summary: [PT dates, duration, adherence, and measured outcomes] • [Medications trialed with durations, outcomes, limiting factors] • [Other modalities with dates and outcomes]
• Prior Procedure Response: [Pre-procedure pain score] → [Post-procedure pain score on same scale] • [Percent relief and duration] • [Functional improvement] (Only include if repeat request)
• Rationale: [2–4 sentences explaining why this procedure is indicated now, alternatives attempted and why insufficient, and expected measurable benefit]

Target Condition and Diagnostic Basis

Pain Presentation

• Location and distribution: [Anatomic terms and dermatomal/myotomal or regional pattern]
• Pain type: [axial / radicular / referred] • [Neuropathic descriptors if present]
• Severity and course: [stable / worsening / flaring] • [Quantified trend over time]

Diagnosis

• Primary diagnosis (pain generator): [Diagnosis name]
• Secondary contributing diagnoses: [Diagnoses materially affecting the request] (Only include if applicable)

Differential Diagnosis Considerations

[Other conditions considered and why ruled out, citing relevant imaging or specialist evaluations with dates. If red flags present, document findings and explain why requested procedure remains appropriate.] (Only include if payer policy requires exclusion of alternate etiologies)

Symptom Chronology and Functional Impact

Timeline

• Onset date: [MM/DD/YYYY] • Precipitating event: [Event if applicable]
• Current episode start date: [MM/DD/YYYY]
• Prior flares and treatments: [Dates and brief measured outcomes]

Pain Assessment

• Baseline pain score: [Named scale and value]
• Typical pain level: [Named scale and value]
• Worst pain level: [Named scale and value]

Functional Impairment

• Validated tool: [Tool name and score with date]
• Walking tolerance: [Minutes or distance]
• Sitting tolerance: [Minutes]
• Standing tolerance: [Minutes]
• Sleep disruption: [Hours of sleep; awakenings per night]
• Work restrictions: [Specific duties limited or days missed]

Conservative Management Tried

(Provide dates, durations, adherence, measured outcomes, and reasons insufficient. If external records unavailable, document: "PT performed at [facility], dates [range]; records requested.")

Non-Pharmacologic Therapies

(Repeat the following for each therapy tried.)

• Therapy type: [PT / HEP / chiropractic / acupuncture / pain psychology / activity modification / other]
• Dates and duration: [Start date – End date]; [Total weeks/sessions]
• Adherence: [completed / partial / discontinued] • [Attendance % or home frequency]
• Measured outcome: [Change in pain score on named scale] • [Change in function on validated tool or quantified ADL]
• Why insufficient: [Objective reason: residual pain/function limits or adverse response]

Pharmacologic Therapies

(List by class. Include medication name(s), duration, outcome, and limiting factors.)

• NSAIDs: [Medication(s); duration; outcome; limiting factors]
• Acetaminophen: [Duration; outcome; limiting factors]
• Neuropathic agents: [Medication(s); duration; outcome; limiting factors]
• Muscle relaxants: [Medication(s); duration; outcome; limiting factors]
• Topicals: [Medication(s); duration; outcome; limiting factors]
• Opioids: [Medication(s); duration; outcome; risk-benefit assessment] (Only include if applicable)
• Other: [Medication(s); duration; outcome; limiting factors]

Objective Findings

Physical Examination

(Include only exam elements tied to diagnosis and procedure selection.)

• Tenderness/pain reproduction: [Anatomic site and response]
• Range of motion: [Quantified limitations and pain reproduction]
• Neurologic: [Strength grade, sensation distribution, reflexes by level]
• Provocative tests: [Named tests and results]

Imaging and Diagnostics

• [Modality] [Region] [Date]: [Key findings relevant to target/diagnosis]

(Add additional studies as needed. If imaging absent or not indicated, document rationale.)

Prior Interventional History

(Include when requesting a repeat or step-up procedure.)

• Date and procedure: [MM/DD/YYYY; procedure name; level(s)/laterality]
• Agent used: [Local anesthetic ± steroid and dose] (Only include if applicable)
• Pain scores: [Pre: named scale and value] → [Post: same scale and value]
• Percent relief: [Measured % relief] • Duration of relief: [Days/weeks]
• Consistency with agent: [Yes / No]; [Brief explanation]
• Functional change: [Validated tool delta or quantified ADL improvement]
• Complications: [None / description]

Relevant prior spine surgeries: [Procedure type; date; residual symptoms] (Only include if applicable)

Medical Necessity Rationale

Indication-Based Justification

[Summary of how symptom duration and severity, functional deficits, documented conservative therapy, and objective findings support the requested procedure per policy]

Why This Procedure Now

[Explanation of why this is the next appropriate step and why less invasive options are insufficient or inappropriate at this time]

Anticipated Outcomes

• Pain reduction target: [Named scale] decrease of [points or percent]
• Functional improvement target: [Validated tool] improvement of [points or percent] and/or [Quantified ADL targets]

Procedure-Specific Requirements

(Include only the ONE module below that corresponds to the requested procedure.)

For Facet Interventions (MBB/RFA)

• Pain pattern: [Confirms axial pattern without radicular features]
• Functional deficit baseline: [Scale and score]
• Symptom duration threshold: [Duration meets policy requirement]
• Conservative therapy: [Documented with dates, duration, outcomes]
• Diagnostic blocks: [Pre/post same-day pain scores; measured % relief; diary method; duration consistent with anesthetic] (Only include if applicable)
• Repeat RFA: [Sustained benefit meeting policy threshold; duration of prior relief] (Only include if applicable)
• Level count per session: [Number of levels per side; justification if exceeding typical limits]

For Epidural Steroid Injection

• Radicular pain basis: [Objective findings supporting nerve root involvement]
• Imaging guidance/contrast: [Fluoroscopy/CT with contrast; or contraindication documented]
• Active rehab/HEP status: [Participation status and adherence]
• Repeat ESI: [Sustained improvement from prior using same scale and functional metrics] (Only include if applicable)

For Sacroiliac Joint Injection

• Pain location: [Consistent with SIJ pattern]
• Provocative maneuvers: [Three or more named positive tests with results]
• Conservative therapy: [Duration and objective failure]
• Diagnostic SIJI: [Required % relief threshold; pre/post same-day scores; diary documentation] (Only include if applicable)
• Therapeutic SIJI: [Sustained benefit threshold and duration met] (Only include if applicable)
• Imaging/contrast plan: [Guidance modality and contrast plan or contraindication]

For Spinal Cord Stimulation (Trial or Permanent)

• Prior treatments across modalities: [Documented attempts and outcomes]
• Psychological evaluation: [Completion date and conclusion: appropriate candidate]
• Trial details: [Trial dates; percent pain reduction achieved; functional/medication reduction metrics] (Only include for permanent implant requests)

Safety and Risk Considerations

(Include only factors relevant to this patient.)

• Anticoagulation/antiplatelet management: [Agent; hold/bridge plan; coordination with prescribing clinician]
• Diabetes considerations: [Monitoring plan; thresholds; coordination] (Only include if corticosteroids planned)
• Contrast allergy: [Premedication or alternative imaging plan]
• Other risk factors: [Implants, infection risk, anatomic variants, BMI, OSA, etc.]

Follow-Up Plan

• Scheduled follow-up: [Timeframe post-procedure]
• Re-measurement scales: [Named pain scale and functional tool to be repeated]
• Criteria for escalation/repetition/discontinuation: [Objective thresholds aligned with payer policy]
• Diagnostic block documentation: [Diary instructions and post-procedure assessment timing] (Only include if applicable)

Attachments

(Label each with document type and date.)

• [Clinic note(s) – date(s)]
• [Imaging report(s) – date(s)]
• [PT notes or discharge summary – date(s)]
• [Prior procedure note(s) with pre/post pain scores – date(s)]
• [Pain diary or outcomes log – date(s)]
• [Psychological evaluation summary – date] (Only include for implantable therapies)

Attestation and Signature

"I attest that this request is medically necessary based on my evaluation of the patient and review of the medical record."

Clinician Signature: [Signature]

Printed Name and Credentials: [Name, Credentials]

Date: [MM/DD/YYYY]

NPI: [NPI]

(If signature is not yet obtained, flag the document as incomplete and do not submit until signed.)