When health care analysts talk about the overuse of costly imaging studies, the discussion usually focuses on a single test: MRI of the lumbar spine. This MRI is the most commonly performed advanced imaging study in the US for two reasons. Firstly, low back pain is a very common problem. Secondly, almost every specialist sees patients with back pain – neurologists and orthopedists, rheumatologists and neurosurgeons, family physicians and and internists and OB-GYNs, even endocrinologists, nephrologists and gastroenterologists.
Among radiology benefits management companies (RBMs), MRI of the lumbar spine is also the most commonly DENIED study. More peer-to-peer calls (P2Ps) are performed for requested and denied MRI lumbar spine than any other imaging study. Many of these denials and P2Ps are avoidable, if only providers learned the a few simple tips from the MRI lumbar spine guideline. That’s the subject of the next two blog posts.
At the RBM company I worked for, the reason for the denial was almost always as follows: “we cannot approve of this MRI lumbar spine because of the lack of either
1. a red flag sign or
2. failure to improve after a 6 weeks trial (during the past 3 months) of provider-guided conservative treatment and a follow up spinal exam.”
This seems like a simple explanation for denial and is based entirely on the RBM’s guidelines, but dissecting each part of this denial rationale will clear up the misunderstandings that lead to so many denials. After reading these two posts, you should be able to obtain authorization on MRI lumbar spine every time.
Red flag signs
Traditionally red flag signs are warning signals. For MRI Lumbar spine, red flags are those clinical signs or symptoms that represent the potential for life- or limb-threatening conditions. As the rationale states, if only a single red flag sign is present, an MRI will be approved without the usual 6 weeks to enable conservative therapy to work. If a red flag is NOT present, an MRI cannot be approved unless the patient has had 6 weeks of unsuccessful conservative treatment. (See my next post for more about conservative treatment.)
Red flags are present if the patient has:
Weakness – Significant motor weakness (unilateral or bilateral) of the lower extremity, foot drop, or loss of reflexes. Myelopathic upper motor neuron signs/symptoms also warrant immediate MRI.
Suspected Abdominal Aortic Aneurysm: known or suspected AAA with acute incapacitating back pain or a history of coronary or peripheral artery disease.
Known or Suspected Cancer: Back pain with a past history of a cancer that commonly metastasizes to the spine OR suspected spinal metastasis and one of the following:
· age greater than 70 years
· pain unrelieved by change in position
· severe & worsening pain despite 1 week of conservative care.
· night pain
· uncontrolled weight loss
· Any patient with stage IV cancer and new onset of back pain. The cancers that commonly metastasize to the spine include melanoma, myeloma, renal cell, prostate, breast, lymphoma and GI tract, but other cancers may spread to the vertebra as well.
Cauda equina syndrome, one or more of the following:
· saddle anesthesia
· decreased anal sphincter tone
· acute onset bilateral sciatica
· bowel/bladder incontinence
· acute urinary retention
Fracture, one or more of the following:
· suspected fracture following trauma such as ejection from motor vehicle, high speed MVA, or fall from significant height
· age over 70
· steroid use
· low bone mineral density
· history of prior low energy fracture
long term use of systemic glucocorticoids
recent significant trauma at any age
Infection, one or more of the following:
· recent bacterial infection
· age over 70.
· chronic dialysis
· immuno-compromised states
· long term use of systemic steroids
· organ transplant
· clinical suspicion of disc space infection or osteomyelitis
· history of IV drug use
Lesson: To avoid denials and subsequent peer-to-peer calls when requesting MRI lumbar spine, first review the RBM company’s guidelines. If a red flag sign is present, an MRI can be approved immediately without the traditional 6 weeks of conservative therapy. The next post will spell out the second half of the denial rationale that confuses many providers: conservative treatment.