Depending on the procedure codes entered for authorizations, the following documentation may be required. In very few circumstances, additional information that is not listed may be requested.
For every authorization, regardless of service, please include an office visit note with TWO (2) patient identifiers.
We encourage all users to print this checklist and utilize it when submitting viscosupplementation requests.
Attempted and failed non-operative/ non-drug therapy
|Physical therapy & duration|
|Medication or steroid injection||Have attempted medications OR steroid injections OR document contraindication|
|If the patient has had a previous visco injection:|
|Outcome of prior treatments||
Include the percent (%) of relief from previous injections + the date of last injection*
*at least 6 months should have passed since last treatment