EPIDURAL INJECTIONS FOR LUMBAR BACK PAIN - PRIOR APPROVAL FORM PART A MUST BE COMPLETED FOR ALL REQUESTS – GP/CONSULTANT DETAILS Name: GP Practice Code: Address: Trust: Preferred Contact (Email) - Only NHS.NET addresses are @nhs.net acceptable: DETAILS PATIENT’S NHS No: MRN (if applicable): Date of Birth: Requesting clinician please confirm the following – Patient Consent: The Patient hereby gives consent for disclosure of information Yes No relevant to their case from professionals involved and to the CCG. I have informed the patient that this intervention will only be funded where the criteria Yes No are met. I confirm that I have reviewed the patient against the commissioning criteria and that Yes No the information provided within this application is accurate. PART B MUST BE COMPLETED FOR ALL REQUESTS – ACCESS CRITERIA Radicular pain consistent with the level of spinal involvement, demonstrated through Yes No appropriate imaging OR Yes No evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise-positive between 30 and 70 degree or positive femoral tension sign) AND symptoms persist despite some non-operative management for at least 6 Yes No weeks
EPIDURAL INJECTIONS FOR LUMBAR BACK PAIN - PRIOR APPROVAL FORM PART A – MUST BE COMPLETED FOR ALL REQUESTS GP/CONSULTANT DETAILS Name: GP Practice Code: Address: Trust: Preferred Contact (Email) - Only NHS.NET addresses are acceptable: @nhs.net PATIENT’S DETAILS NHS No: MRN (if applicable): Date of Birth: Requesting clinician – please confirm the following Patient Consent: The Patient hereby gives consent for disclosure of information relevant to their case from professionals involved and to the CCG. Yes No I have informed the patient that this intervention will only be funded where the criteria are met. Yes No I confirm that I have reviewed the patient against the commissioning criteria and that the information provided within this application is accurate. Yes No PART B – MUST BE COMPLETED FOR ALL REQUESTS ACCESS CRITERIA Radicular pain consistent with the level of spinal involvement, demonstrated through appropriate imaging OR evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise-positive between 30 and 70 degree or positive femoral tension sign) Yes Yes No No AND symptoms persist despite some non-operative management for at least 6 weeks Yes No
Epidural-Injections-Prior-Approval-Form.docx