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4787 E Camp Lowell Dr, Tucson, AZ 85712
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ANTERIOR LUMBAR INTERBODY FUSION (ALIF):
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2018-12-24T09:35:51-07:00
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UHC Spine Surgery Request Form?
Yes
Member Information
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TIN/NPI
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Fax
Servicing Facility
Camp Lowell Surgery Center
St. Mary's Hospital
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Servicing Facility Address (Camp Lowell)
4620 E Camp Lowell Dr, Tucson, AZ 85712
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Servicing Facility Address (St. Mary's)
1601 W St Mary’s Rd, Tucson, AZ 85745
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Facility TIN/NPI (Camp Lowell)
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Facility TIN/NPI (St. Mary's)
Diagnosis
Chief Complaint
Axial back pain
Axial neck pain
Cervical radiculopathy
Gait & balance problems
Inability to stand up straight
Inability to walk for extended distances
Loss of fine motor control
Low back pain
Lumbar radiculopathy
Sacroiliac joint pain
Sciatica
Spinal deformity
Thoracic back pain
Thoracic radiculopathy
Surgery
Select One
Anterior Cervical Discecomty and Fusion (ACDF)
Anterior Lumbar Interbody Fusion
Laminoforaminotomy with Rhizotomies
Laminoforaminotomy with Rhizotomies and Hardware Removal
Laminoforaminotomy Microdiscectomy with Rhizotomies
Laminoforaminotomy Microdiscectomy
Cervical Laminoforaminotomy with Rhizotomies
Lumbar Hemilaminectomy, Foraminotomy, Microdiscectomy
Lumbar Laminectomy
Lumbar Laminectomy and in situ Fusion
Posterior Lumbar Interbody Fusion
Posterior Cervical Laminectomy
Posterior Cervical Fusion
Posterior Spinal Fusion
Posterior Cervical Copectomy
Transforaminal Lumbar Interbody Fusion (TLIF)
Posterior Cervical Foraminotomy
How many levels?
Single
2 Levels
Multi
Had Previous TLIF at same level(s)?
Yes
No
CPT: Laminoforaminotomy with Rhizotomies and Hardware Removal
CPT: Laminoforaminotomy with Rhizotomy
CPT: Laminoforaminotomy Microdisectomy
CPT: Posterior Cervical Foraminotomy (Single)
CPT: Posterior Cervical Foraminotomy (Multi)
CPT: Posterior Cervical Foraminotomy (Multi)
CPT: ACDF (Single)
CPT: ACDF (2 Levels)
CPT: ACDF (Multi)
CPT: ALIF (Single)
CPT: ALIF (Multi)
CPT: ALIF (Multi)
CPT: TLIF (Single)
CPT: TLIF (2 Level)
CPT: TLIF (Multi)
CPT: TLIF (Single - Prev)
CPT: TLIF (2 Level - Prev)
CPT: TLIF (Multi - Prev)
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