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Thoracic Spine MRI Imaging Questionnaire 1. INSTRUCTIONAL NOTE: Advanced Imaging UR program applies ONLY to STATE FUND WORKERS’ compensation claims. For authorization of services pertaining to Self-Insured claims, please contact the injured worker’s employer or the third party administrator. 2. (Mandatory) DISCLAIMER: This is a guideline-based review that will result in a recommendation only. L&I must make the final determination of payment based on legal claim validity. Approval should occur within 24-48 hours. Acknowledge 3. SECTION A: ACUTE THORACIC BACK PAIN (ONSET W/IN PAST 6 WEEKS): MRI without contrast unless specified otherwise: Yes No 4. A1 - If Yes, select one: Bilat neuro weakness in low extrem by PE Focal pain follow fall from ht or trauma Bladder/bowel dysfunction follow trauma Sx compatible w/focal radiculopathy Infection: MRI w/o, w/contrast (go to 7) Hx of cancer w/new pain (go to 6) Suspicion of cancer w/new pain (go to 6) Low velocity trauma, >70yrs (go to 8) Osteoporosis, > 70yrs (go to 8) NA 5. A2 – Is there History or suspicion of cancer with new onset of thoracic pain? Yes No 6. A3 – If Yes, History or suspicion of cancer criterion can be met if any TWO of the following are present (select two): Age over 50 Failure to improve after one month Unexplained weight loss NA 7. A4 – If answer is Infection: MRI without and with contrast, select one: Elevated sedimentation rate Fever Immunosuppression (e.g. steroid use) IV drug use Known bacteremia Suspicion of systemic or spinal infection NA 8. A5 – If answer is Low velocity trauma OR osteoporosis, AND/OR age > 70 years, select one: Vertebral compression on x-ray Other fractures NA Thoracic Spine Imaging updated 02/09/2011 1 9. SECTION B: SUBACUTE THORACIC BACK PAIN > 6 WEEKS, MRI W/O CONTRAST. Did the patient have MEDICAL/CONSERVATIVE CARE? If No, stop and submit the questionnaire. Request will be pended and reviewed by Qualis Health. Yes No Thoracic Spine Imaging updated 02/09/2011 2