Commercial Injections

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 the following services for commercial members:

  • Sacroiliac joint injections (SI joint)
  • Spine facet joint injections
  • Initial & repeat spine radiofrequency ablation(RFA)
  • Epidural steroid injections (ESI)
  • Medial branch block (MBB)
Documentation Details
Advanced imaging
  • MRI and/or CT scan
  • Dated imaging report

SI joint provocative testing

*only for SI joint injections*

Documentation of a minimum of 2 tests. 

  • Includes: Patrick‚Äôs or FABER, Gaenslen, thigh thrust, sacral thrust, distraction, compression
Functional impairment of Activity of daily living (ADLs) Include pain scale and any pain-causing movements
Outcome of prior treatments If applicable, the percent (%) of relief from previous injections and duration of relief
Patient information Most recent office visit note(s)
Conservative Therapy

Include duration and dates of therapy.

*Depending on procedure 6 or 12 weeks may be requested

  • Activity/ lifestyle modifications
  • Home exercise program
Physical Therapy

Including home exercise program (HEP) with duration and dates

Medications Non- steroidal anti-inflammatory drugs, Non-Narcotic Analgesics, Narcotic Analgesics, Neurogenic Pain Medication (Gabapentin, Lyrica, etc.)
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