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):

Avascular necrosis (osteonecrosis), humeral head Nonunion or malunion, articular fracture

Bone tumor by imaging Osteoarthritis

Intra-articular fracture by imaging Rheumatoid arthritis

Other:

Symptoms (please check all that apply):

Avascular necrosis with collapse of humeral head by imaging Pain at shoulder increased with initiation of activity

Bone-on-bone contact with angular deformity by imaging Pain at shoulder interferes with ADLs

Crepitus with glenohumeral joint rotation Pain with ROM

Humeral head fracture 3 parts Periarticular osteopenia

Joint space narrowing by x-ray Periarticular osteophytes

Joint subluxation Repair achievable by open reduction and fixation

Limited ROM Subchondral cysts

Marginal erosions Subchondral sclerosis

Nonunion or malunion of fracture, glenoid Symptomatic avascular necrosis

Nonunion or malunion of fracture, humeral head Other:

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 Disease-specific therapy 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 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 .

HSV-FORM-174 (12/14)