Member S Name: Member S DOB s2

Shoulder 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): Acromioplasty for chronic rotator cuff tendonitis Release of adhesive capsulitis Chrondroplasty Removal/stabilization of intra-articular lesion/loose body Decompression of subacromial space for chronic rotator cuff tendonitis Repair of full thickness rotator cuff tear Joint exploration post penetrating joint injury Repair of labral tear/superior labral anterior posterior lesion Joint lavage with joint aspirate diagnostic for infection Repair of partial thickness rotator cuff tear Recurrent anterior dislocation Resection of distal clavicle

Symptoms (please check all that apply): Active compression test, positive Osteochondral lesion of glenoid or humeral head by imaging ADLs affected Pain, shoulder for weeks/months Anterior slide test, positive Pain, shoulder with movement Chronic tendonitis Pain on resisted shoulder abduction or rotation Clicking or catching Partial thickness rotator cuff tear by imaging Crank test, positive Passive ROM normal or greater active ROM Crepitus Periarticular osteophytes Degenerative changes in bone/cartilage, minimal Popping Degenerative changes in bone/cartilage, none Range of motion limited Dislocation on 2 or more episodes within 2 years documented by imaging Rotator cuff tear by imaging, minimal Fracture, none Rotator cuff tear by imaging, none Fracture, anterior glenoid rim Shoulder injury by history Giving way by history Subchondral cyst Hill-Sachs lesion Subchondral sclerosis Joint space narrowing Symptomatic osteochondrial lesion/loose body by imaging Joint subluxation Tenderness over rotator cuff Locking or catching Tenderness, subacromial Osteoarthritis by imaging, mild Traumatic event by history Osteoarthritis by imaging, none Weakness on resisted shoulder abduction/rotation Other:

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HSV-FORM-173 (12/14) Previous Treatments (please check all that apply): Acetaminophen therapy for weeks Home exercise for weeks Activity modification for weeks NSAID therapy for weeks OT/PT for weeks Subacromial corticosteroid injection 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 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-173 (12/14)