The following information is for dates of service March 1, 2016, and after. For information regarding dates of service before March 1, 2016, click here.
Dates of service March 1, 2016, and after
Effective March 1, 2016, the following two changes go into effect for members with low back pain:
- These members are no longer required to see a physical medicine and rehabilitation provider for evaluation prior to referral to a neurosurgeon or orthopedic surgeon. The requirement for a referral to a physical medicine and rehabilitation provider had been part of BCN's Spine Care Referral Program.
- Clinical review is no longer required for the initial visit to a neurosurgeon or orthopedic surgeon and for office visits and procedures. These visits may require a referral from the member's primary care physician, depending on the region.
These changes apply to BCN HMOSM (commercial) and BCN AdvantageSM members who have a low back pain condition defined by the select ICD-10 diagnosis codes that were previously subject to these requirements as part of BCN's Spine Care Referral Program.
The Spine Care Referral Program page on this website will reflect this information by March 1.
For additional information on BCN's referral requirements, which vary by region, refer to the BCN Referral / Clinical Review Program, available on the Clinical Review & Criteria Charts page on this website. Information on requirements for clinical review is also available in that document.
Dates of service before March 1, 2016
The Blue Care Network Spine Care Referral Program is designed to ensure that all members with ongoing low back pain appropriately receive comprehensive and timely nonsurgical evaluation of their symptoms and condition prior to surgical evaluation.
The Spine Care Referral Program applies to nonemergent and nonurgent requests for referral and consultation to a neurosurgeon or orthopedic surgeon for the purpose of evaluation of low back pain. This includes global referrals and excludes consults done during an emergency department visit or during an inpatient admission. All members age 18 or older with low back pain must be seen by a physical medicine and rehabilitation provider prior to referral to a neurosurgeon or orthopedic surgeon for select conditions, as defined by the specified diagnosis codes.
Submit requests on e-referral
Providers will be prompted to answer questions about the member's condition, when the member was seen by a PM&R specialist, the PM&R specialist's name and the date of that visit. If a member has not seen a PM&R specialist, e-referral will prompt the referring provider to provide the rationale for the referral to the neurosurgeon or orthopedic surgeon.
All requests for members without a "red flag" condition, who have not been evaluated by a PM&R specialist, have not been recommended for a surgical evaluation and have not failed conservative treatment, will pend for clinical review. BCN clinical staff will review the information provided for appropriateness and make a determination on the request for the office visit or consultation, or send to the plan medical director for review and determination.
Referral to a PM&R provider should include the following information:
- Request for evaluation and recommendations by PM&R specialist, or request for evaluation and treatment by the PM&R specialist.
- Any diagnostic or imaging test result should accompany the member to the visit
- Current and pertinent medical history.
- Other consultant findings and treatment, or other interventions for the treatment of this condition.
- Prior therapy and specialist consultant names.
Members appropriate for consultation to a neurosurgeon or orthopedic surgeon without a referral to a PM&R specialist
Consultation to a neurosurgeon or orthopedic surgeon may be granted if the member has one of the following conditions, based on "red flags" indicating serious disease as found in the Michigan Quality Improvement Consortium Guidelines — MQIC Management of Acute Low Back Pain:
- Cauda Equina Syndrome
- Severe progressive neurologic deficit (for example, numbness or weakness spreading to one or both legs, causing difficulty with ambulation)
- Recent bowel or bladder dysfunction
- Saddle anesthesia (altered sensation over the "saddle area" of the hips, buttocks and inner thigh)
- Space occupying lesions
Spine Care Referral Program authorization — sample questionnaire
When requesting authorizations for spine evaluations on e-referral, the system will prompt the submitter to complete a questionnaire to determine the appropriateness of the request.
To search for a PM&R specialist, go to bcbsm.com and follow these steps:
- Click Find a doctor
- Under Quick Search, click Get Started.
- Click the fourth option, Advanced Search.
- In Step 1: Enter the radius and location criteria (ZIP Code, street address or county).
- In Step 2: Select the member's plan from the drop-down.
- In Step 3: Select Doctor, Specialist and Medical Professional.
- In Step 4: Type in "Physical medicine and rehabilitation."
- Click Go.
For more information
For additional details about the Spine Care Referral Program, read the comprehensive spine program description (PDF).
Read the steps and recommendations for a smooth referral to an orthopedic surgeon or neurosurgeon in the Spine Care Referral Process summary (PDF).