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L Yes in skeletally mature patients with degenerative disc disease l No Is this from the fourth lumbar vertebra L4 to the first sacral vertebra S1. L Yes Does the member have degenerative disc disease defined as disco genic back pain with degeneration of the disc confirmed by patient history and radiographic studies. L Yes If yes date range of treatment 831-00057-31 12/14 2014 Security Health Plan of Wisconsin Inc. Effective 6/2014 Summary of nonoperative treatment By signing this form the...

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