Facet Nerve Block Medial Branch Block

HUMANA Pain Management Prior Authorization Request …

Facet Medial Branch Nerve Block: Local Steroid RFA 1. Primary Diagnosis Code Cervical Thoracic Lumbar Sacral Please Select Spinal Region(s) which applies: If yes, ____% Pain Relief lasted ____ weeks from last (Epidural or Facet injection) performed on Date:_____ 4. Previous Epidural or Facet Injections(s)? Yes No

  Management, Request, Authorization, Never, Block, Pain, Prior, Branch, Humana, Mailed, Facet, Humana pain management prior authorization request, Facet medial branch nerve block

Low Back Disorders

New York State Workers’ Compensation Board New York Mid and Low Back Injury Medical Treatment Guidelines Third Edition, September 15, 2014 iii