Predetermination Request for Facet Joint Denervation

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* Required Field

Enter Patient Information

  • Review Type:
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • IDC-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.
  • CPT or HCPCS Codes: *
    (Include modifiers if applicable)
  • CPT/HCPCS codes must contain 5-9 charactersUnits may contain up to 3 characters
    Units:
  • Date of Service/Admission Date: *

* Required Field

Enter Provider Information

  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address:
  • Contact Phone No:*
  • Contact Phone Ext:
  • Contact Fax No:*
  • Provider ID OR NPI: *
  •  
    • I am an Ordering Physician
    • I am a Servicing Physician
  • Ordering Physician's Name:
  • Ordering Physician's Address:
  • Ordering Physician's City:
  • Ordering Physician's State:
  • Ordering Physician's Zip:
  • Ordering Physician's Email Address:
  • Ordering Physician's Phone No:
  • Ordering Physician's Fax No:
  • Servicing Physician's Name:
  • Servicing Physician's Address:
  • Servicing Physician's City:
  • Servicing Physician's State:
  • Servicing Physician's Zip:
  • Servicing Physician's Email Address:
  • Servicing Physician's Phone No:
  • Servicing Physician's Fax No:
  • Facility/Supplier Name: *
  • Facility NPI:
  • Facility/Supplier Address: *
  • Facility/Supplier City: *
  • Facility/Supplier State: *
  • Facility/Supplier Zip: *
  • Which levels and side(s) are being requested for treatment? *
  • Method of denervation: *
  • RFA
  • Pulsed RFA
  • Laser
  • Chemo
  • Cryo
  • Other

History and Physical: *

Duration of Symptoms: *

Conservative treatments used and duration of those treatments: *

Symptoms and History: *

  • YesNo
  • Does the patient have radiculopathy?
  • YesNo
  • Does the patient have a history of fusion at the proposed treatment level (s)?
  • YesNo
  • Does the patient have a history of RFA at the proposed treatment level? If yes, date of RFA treatment:
  • Date of 1st diagnostic medical block:
  • Percentage of Relief:
  • Date of 2nd diagnostic medical block:
  • Percentage of Relief:

Note: if member has had a prior successful RFA at the same level/side in the past (at least 6 months prior) a repeat diagnostic medical branch block is not required and would be not medically necessary.

Radiology Report Interpretation: *

Please attach relevant clinical documentation.*

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







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If you experience issues submitting this form, please print and fax it to (816) 817-8211.

If you have questions, contact Blue KC at (816) 395-3989.

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IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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