Member S Name: Member S DOB s1

Knee Arthroscopy Preauthorization Form

Please complete this form completely. NOTE: For your patient to receive the lowest out-of-pocket costs, use in-network providers unless preauthorization is obtained from Avera Health Plans. Check the Avera Health Plans Provider Directory at AveraHealthPlans.com. Decisions are based on eligibility, benefit determination and medical necessity.

Member’s name: Member’s DOB: Member’s ID Number: Group Number: ICD code(s), please list all that apply: CPT code(s), please list all that apply: Where will procedure take place? Date of procedure: Procedure will be: outpatient inpatient

Conditions (please check all that apply): Chondroplasty Removal/stabilization of intra-articular lesion/loose body Joint exploration post penetrating joint injury Resection/repair of stable/unstable meniscal tear Lateral release Synovectomy, limited Lavage of joint w/ joint aspirate diagnostic for infection Synovectomy, major

Symptoms (please check all that apply): Crepitus McMurray test positive Degenerative changes in bone/cartilage, minimal Meniscal tear Degenerative changes in bone/cartilage, none Osteochondral lesion/body, symptomatic Giving way by history Pain with flexion & rotation Imaging nondiagnostic Patellar/peripatellar pain Joint effusion/swelling Patellar tilt, abnormal Joint line tenderness Patellar tilt, excessive Joint pain Q angle >20 degrees Knee locking by history or exam Retropatellar crepitus Lateral subluxation > 1cm Tenderness over suspected plica Limited ROM Other:

Previous Treatments (please check all that apply): Acetaminophen therapy for weeks Home exercise or PT for weeks Activity modification for weeks NSAID therapy for weeks External joint support for weeks Other:

Did symptoms or findings continue after treatment? Yes No Please Explain:

Prescriber Name: Today’s Date: Person completing the form: Your Office/Facility Name: Your Phone Number: ( ) Your Fax Number: ( )

IMPORTANT NOTICE: This determination does not guarantee benefits or payment of services. Payment of services is subject to patient eligibility at the time of treatment, benefit plan limitations and the other terms of the benefit plan. Payment of benefits is only made for services deemed medically necessary and appropriate. The final payment decision will be made upon submission of a claim by Avera Health Plans. If you have questions about your benefits, please contact

HSV-FORM-180 (12/14) Avera Health Plans Service Center at 605-322-4545 or toll-free at 1-888-322-2115. This form is not all-inclusive of services requiring preauthorizations. Refer to patient’s Certificate of Coverage or Summary Plan Document for more information. Fax this completed form to Avera Health Plans at 1-800-269-8561 or send secure email to [email protected].

HSV-FORM-180 (12/14)