Fillable Spine Surgery Information Request Form (UMR)

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Spine Surgery Information Request Form (UMR)

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The Spine Surgery Information Request Form (UMR) form is 2 pages long and contains:

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Certain devices and surgical techniques require clinical review to determine whether they are covered
by the member’s policy, and if their utilization is in accordance with FDA-approved indications. Please
provide the following information to assist us in determining coverage of your patient’s planned
procedure:
□ c COMPLETED SPINE SURGERY INFORMATION REQUEST FORM (ATTACHED).
□ c CLINICAL RECORDS, INCLUDING PATIENT HISTORY AND PROGRESS NOTES.
□ c RESULTS OF CONSERVATIVE CARE.
□ c RADIOLOGY REPORTS (X-RAYS/MRI).
You may view UnitedHealthcare policies in detail at:
UnitedHealthcareOnline.com > Policies and Protocols > Medical and Drug Policies.
NOTE: **IF REQUESTED INFORMATION IS INCOMPLETE, PAYMENT FOR THE CLAIM MAY BE DENIED.**
Completion of the notification process is not a guarantee of claims payment. Claims payment is subject to member
eligibility, benefits and application of coverage as outlined in the member’s coverage documents.
CONFIDENTIALITY NOTICE: Information accompanying this fax is considered to be UnitedHealthcare’s confidential and/or proprietary business
information. This information may be used only by the person or entity to which it is addressed. Such recipient shall be liable for using and protecting
UnitedHealthcare’s information from further disclosure or misuse, consistent with applicable contract and/or law. The information you have received
may contain protected health information (PHI) and must be handled according to applicable state and federal laws, including, but not limited to Health
Insurance Portability and Accountability Act (HIPAA). Individuals who misuse such information may be subject to both civil and criminal penalties. If you
believe you received this information in error, please contact the sender immediately.
Spine Surgery Information Request Form
This form is used for UMR members only. Medicare, Medicaid, FHP, or SCHP have their own specific
requirements; please do not use this form.
Please fax the requested information to: 866-912-8464 promptly, as an accurate coverage decision
cannot be made without this information. If you have any questions, or if this request is related to an
emergent request for surgery, please call 800-808-4424 . Thank you.
To: UMR From:
Fax:1-866-912-8464 Fax:
Reference Number: Phone:
Pages (Including Cover):
Notification needs to be completed and Reference Number obtained prior to faxing
this form.
M53886_20140905
Please fax information for UMR employer group members to 866-912-8464
1. WHICH OF THE FOLLOWING SPINE FUSION TECHNIQUES WILL YOU BE USING? PLEASE INDICATE ALL TECHNIQUES.
c ANNULOPLASTY)
c AXIAL LUMBAR INTERBODY FUSION (AxialLIF
c CERVICAL INTERBODY FUSION
c DIRECT LATERAL INTERBODY FUSION (DLIF)
c ENDOSCOPIC LUMBAR FUSION
c EXTREME LATERAL INTERBODY FUSION (XLIF)
c FACET FUSION WITHOUT DECOMPRESSION
c FACET FUSION WITH DECOMPRESSION
c GUIDED LATERAL INTERBODY FUSION (GLIF)
c GUIDED OBLIQUE LATERAL INTERBODY FUSION (GOLIF)
c INTERLAMINAR LUMBAR INSTRUMENTED FUSION (ILIF)
c LAPAROSCOPIC ANTERIOR LUMBAR INTERBODY FUSION (LALIF)
c POSTERIOR LUMBER INTERBODY FUSION (PLIF)
c STANDARD ANTERIOR LUMBAR INTERBODY FUSION (ALIF)
c STANDARD POSTERIOR LUMBAR INTERBODY FUSION (PLIF)
c TRANSFORAMINAL LUMBAR INTERBODY FUSION (TLIF)
c TRANSFORAMINAL LUMBAR INTERBODY FUSION WITH
ENDOSCOPY VISUALIZATION (such as a percutaneous incision with
video visualization)
c PERCUTANEOUS ENDOSCOPIC DISCECTOMY WITH OR WITHOUT LASER
c PERCUTANEOUS LASER DISC DECOMPRESSION
c NUCLEOPLASTY (PERCUTANEOUS DISC DECOMPRESSION)
c PERCUTANEOUS LUMBAR DISCECTOMY
c OTHER SPINAL FUSION TECHNIQUE:
2. WHICH OF THE FOLLOWING OTHER SPINE SURGERY TECHNIQUES WILL YOU BE USING? PLEASE INDICATE ALL TECHNIQUES.
c ACCURASCOPE
c DISCECTOMY
c DSS BRAND STABILIZATION SYSTEM
c DYNESYS® DYNAMIC STABILIZATION SYSTEM
c FORAMINOTOMY
c LAMINECTOMY
c LAMINOTOMY
c MICRODISCECTOMY
c IMAGE-GUIDED MINIMALLY INVASIVE LUMBAR
DECOMPRESSION (MILD®)
c PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY)
c METRX MICRODISCECTOMY SYSTEM WITH VIDEO
VISUALIZATION
c METRX MICRODISCECTOMY SYSTEM WITH DIRECT
VISUALIZATION
c TOTAL ARTIFICIAL DISC REPLACEMENT
PLEASE INDICATE WHICH OF THE FOLLOWING:
c CERVICAL 1 LEVEL c LUMBAR
c CERVICAL 2 CONTIGUOUS LEVELS
c ARTIFICIAL DISC
c CERVICAL 2 NON CONTIGUOUS LEVELS COMBINED WITH FUSION
MUST PROVIDE THE BRAND NAME OF ARTIFICIAL DISC:
c TOTAL FACET JOINT ARTHROPLASTY
c X-STOP PRODUCT
c INTERSPINOUS FIXATION DEVICE (E.G. COFLEX-F DEVICE)
c OTHER SPINE STABILIZATION TECHNIQUE/SYSTEM:
c OTHER SPINAL DECOMPRESSION PROCEDURE
3. WHICH OF THE FOLLOWING PRODUCTS WILL YOU BE USING? PLEASE INDICATE ALL PRODUCTS.
c
NONE
c AUTOGRAFT
c CADAVER ALLOGRAFT
c ANIMAL ALLOGRAFT
c DEMINERALIZED BONE MATRIX;
PLEASE INDICATE WHICH OF THE FOLLOWING:
c ALLOGRAFT DBM c SYNTHETIC DBM
MUST PROVIDE THE BRAND NAME:
c AMNIOTIC TISSUE MEMBRANE
c BONE MORPHOGENETIC PROTEIN-7 (BMP-7)
c BONE MORPHOGENETIC PROTEIN-2 (BMP-2);
PLEASE INDICATE WHICH OF THE FOLLOWING:
□c INFUSE™ BONE GRAFT/LT-CAGE LUMBAR TAPERED FUSION DEVICE
□c INFUSE™ BONE GRAFT/INTERFIX™ THREADED FUSION DEVICE
□c INFUSE™ BONE GRAFT/INTER FIX™ RP THREADED FUSION DEVICE
□c OTHER CAGE TYPE (for example PEEK or other);
MUST PROVIDE THE BRAND NAME
c CERAMIC-BASED PRODUCTS;
PLEASE INDICATE WHICH OF THE FOLLOWING:
c BETA TRICALCIUM PHOSPHATE ( b-TCP)
c OTHER: MUST PROVIDE THE BRAND NAME:
c CELL-BASED PRODUCTS;
PLEASE INDICATE WHICH OF THE FOLLOWING:
c MESENCHYMAL STEM CELLS c OSTEOCEL
c TRINITY EVOLUTION
c INFUSE/MASTERGRAFT POSTEROLATERAL REVISION
DEVICE SYSTEM
c OPTIMESH
c PLATELET-RICH PLASMA (PRP)
c OTHER PRODUCT(S); MUST PROVIDE THE BRAND NAME:
CLINICIAN IS REQUIRED TO COMPLETE THIS PORTION OF THE FORM
NOTE: This form is not for use for members of Medicare (including Secure Horizons/AARP), Medicaid, FHP, or SCHP plans.
Patient’s Full Name: Date of Birth:
Member ID: Person completing the form:
Patient’s Phone: Phone :
Spine level(s): c Inpatient c Outpatient c Observation
M53886_20140905
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Spine Surgery Information Request Form (UMR)

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Completed 2 January 2022

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