The reason used by Radiology Benefits Managers (RBMs) to deny MRI lumbar Spine is almost always the same: “we cannot approve of this MRI lumbar spine because of lack of either
a. a red flag sign or
b. failure to improve after a recent 6 weeks trial (during the past 3 months) of provider-guided conservative treatment and a follow up spinal exam.”
In the last blog
I discussed what a red flag sign was. This post will explain in more detail the second part of the rationale: failure to improve after 6 weeks of conservative treatment. It seems self-evident, but this rationale is often misunderstood leading to countless denials and peer-to-peer appeals.
While performing thousands of peer-to-peer conversations with physicians, I discovered that the term “conservative treatment” is not understood the same by all doctors. Some orthopedists equate conservative treatment primarily with physical therapy. During these p2p calls, I explain that, while PT is certainly considered conservative treatment, it is by no means the only treatment included by that term. Conservative treatment can also be
· activity modification
· non-steroidal anti-inflammatory drugs (NSAIDS)
· narcotic and non-narcotic analgesics
· oral or injectable steroids
· acute pain treatment (rest, ice, heat, exercises)
· a physician-directed home exercise/stretching program, spinal manipulation, patient education, chiropractic treatment,
· physical or occupational therapy
· any other pain management techniques OR 6 weeks of OBSERVATION.
Any one or more (alone or in combination) of these interventions count as conservative treatment and should be communicated to the RBM nurse when requesting prior authorization. Note that observation can be a substitute for medicine or therapy (tincture of time).
Another source of confusion is the TIME requirement for conservative treatment:
6 weeks (or more) during the past 3 months.
This guideline calls for recent treatment during this time frame, but it does NOT specify that the entire treatment rendered must be provided by the same doctor. In fact, if several providers have treated the patient, the total time may be included in that 6 week time frame.
For example, if an orthopedist is requesting an MRI lumbar spine, and the primary care physician (PCP) has been treating the patient with non-steroidals for the past 2 months, the time requirement has been met. If a patient sees a convenient care center provider with acute lumbar pain and starts meloxicam, then follows up with the PCP for the next 6 weeks, that also meets the requirement.
In order to be certain that the requested MRI will be approved, it is critical that your office PAL (prior authorization liaison) give sufficient clinical history demonstrating that at least 6 weeks of therapy have been provided. Better yet, your PAL can communicate to the RBM nurse that treatment was started on a specific date, and a follow up re-evaluation took place on another date that is at least 6 weeks later. When this clinical information is provided to the intake nurses, they will have no choice but to approve the request.
One more source of guideline confusion centers upon whether an actual office visit is required before approval of an MRI lumbar spine. Most RBM guidelines do require an actual face-to-face visit for the initial visit, but they do not require that visit to be with the requesting provider. The moment the patient sees any provider for back pain, the clock starts ticking toward that 6 week time frame. For the follow-up evaluation, however, most guidelines do not require a face-to-face visit – a telephone call, e-mail, or instant messaging may suffice.
During P2P calls, physicians often ask why RBM guidelines call for 6 weeks of conservative treatment. There are two reasons for this rule. Firstly, this requirement is taken from evidence-based guidelines published by many national specialty organizations including the American College of Physicians and 10 others. All of these guidelines contain the same statement: Do not perform an MRI Lumbar Spine without a red flag OR 6 weeks of unsuccessful conservative therapy.” Study after study have demonstrated that during that 6 week time frame, 85% of patient with low back pain will obtain sufficient relief that they will not need to have an MRI.
A second reason for the 6 week time frame has to do with the number of false positive MRI scans. It has been repeatedly demonstrated that as patients age, an increasing number of MRI scans show bulging disk, protruding disk or even extruding disk even in the absence of back pain. One study showed that nearly 60% of asymptomatic patients over 50 will show some MRI abnormality. By waiting 6 weeks, many of these patients will improve and will not need imaging, reducing the chance that a patient with a false positive MRI will end up with unnecessary surgery.
Lesson #9: Once you understand the details of the MRI lumbar spine guideline, the definition of red flags, and what constitutes conservative therapy, you will find it easier to meet the guidelines and obtain prior authorization for the MRI “right out of the gate.”
A few more quick tips to help you obtain spinal imaging are included in the next posting.