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Your clinical note should outline: Relevant diagnosis (radiculopathy of lumbar region, herniated disc, or spinal stenosis) Indications for the procedure (lack of progress after conservative therapy, MRI results, etc.) Supplementary details such as: Level(s) of the spine treated, technique employed, medications administered, and imaging performed, if applicable, while noting laterality: left, right, or bilateral Response to previous injections, if applicable This documentation is often mandatory by the payers and Medicare LCDs, particularly in the field of pain management