Cervical Discectomy Checklist
A Cervical Discectomy is a type of neck surgery that involves removing a damaged disc to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. Documentation Requirements for cervical discectomy includes:
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No |
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Indicate if this request is an expedited review for cervical discectomy |
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Documentation submitted supports a condition or diagnosis for cervical discectomy |
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The procedure requested is indicated for cervical generative disc disease C3 to C7 |
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Documentation supports that conservative treatments have been attempted for 6 weeks for intractable cervical pain or myelopathy |
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The patient has severe or rapidly progressive symptoms of nerve root or spinal cord compression requiring immediate surgical intervention |
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Documentation submitted support pain characteristics and/or interference with activities of daily living (ADLs) |
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Physician order for the procedure/device |
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Documentation supports that conservative treatments have been tried and failed |
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Oral steroid therapy |
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Analgesics |
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Physical therapies |
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Epidural block |
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Reduced activity |
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Other — Please list |
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Documentation includes radiological evidence of nerve root or spinal cord compression (CT scan, MRI or Myelography) |
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Does the beneficiary have any contraindications to cervical discectomy? |
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Extreme obesity (BMI of 40 of greater) |
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Significant cervical anatomical deformity |
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Allergy or sensitivity to implant materials |
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Active systemic infection at the operating site |
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Osteoporosis or osteopenia |
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Marked cervical instability |
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Severe spondylosis |
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Clinically compromised vertebral bodies at affected level |
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