During the years I worked as medical director for a Radiology Benefits Manager (RBM), I was amazed how some imaging requests were denied over and over again for the very same reason for the same requesting doctor. While performing peer-to-peer calls with these providers, I often tried to teach them how to keep from falling into the same trap, but time was limited and physicians needed to get back to their patients. MRI of the shoulder was one such imaging study. Nearly 90% of all denied request were rejected for the same reason. This post will clarify that reason, and in doing so, may put a stop to the many peer-to-peer calls.
Denial Reason Number One – What does it mean?
The most common reason for a shoulder MRI denial is for “lack of 6 weeks (during the past 3 months) of unsuccessful physician-directed conservative treatment followed by clinical re-evaluation.” The wording of this rationale is often misunderstood. In this post, I will break down and clarify this denial rationale.
“6 weeks of conservative treatment” Many physicians equate this term to mean ‘physical therapy,’ and so if their patient has not received a full 6 weeks of PT, this guideline criteria could not have been met. During peer-to-peer calls, I often explained that while PT is certainly considered one type of conservative treatment, it is by no means the only treatment modality included in that term.
“Conservative treatment” can also mean
rest, ice, compression and elevation (RICE) especially for acute injuries
narcotic and non-narcotic analgesics
oral or injectable corticosteroids
a provider-directed home exercise program
physical and/or occupational therapy
immobilization by splinting/casting/bracing
medical devices (splints, stabilizers).
Frequently Asked Questions
Q: Does the “6 weeks of conservative treatment” rule require the same treatment for the full 6 weeks?
A: No. Any of the above treatments can be administered, alone, in combination, or sequentially, as long as some treatment is performed over a period of 6-weeks.
Q: When does the “6 weeks time-frame” start?
A: The 6-week “clock” starts ticking at the time of first provider contact for shoulder pain, regardless of the time of injury or onset of pain.
Q: Must the treatment be administered for 6 weeks by the same provider?
A: No. The “treatment clock” begins when that first provider sees your patient. The provider might be an ER physician, a NP in a convenient care center, a chiropractor or the primary care physician. Follow up visits and requests for MRI, if no improvement, may be with the patient’s PCP, an orthopedist, or other provider, as long as a total of 6 weeks have elapsed since the first visit. It is helpful if the follow-up provider documents the date of the first visit to convince the prior authorization nurse that the time-frame has been met.
If an orthopedist sees a patient who has already had 6 weeks of treatment by other providers, the time-frame has already been met, and it is not necessary to provide additional treatment, the MRI should be approved. It is helpful to document all dates of previous providers so the RBM nurses do not mistakenly deny the claim.
Q: The guideline calls for a visit by a provider. What do RBMs consider a provider?
A: A provider may be a physician, physician assistant, nurse practitioner, or a chiropractor, in any clinical setting (office, ER, convenient care center). In states that allow direct access to physical therapists, a PT visit may count as a provider visit and can be the initial visit.
Q: The denial rationale states that patients must have an initial clinical evaluation and then reevaluation after treatment. Must both of these evaluations be face-to-face office visits?
A: The initial encounter must be a face-to-face visit with physical examination with a provider (and remember the initial visit does not have to be with the provider who subsequently requests the MRI). First visits could even be with an ER physician or a convenient care center provider. After the 6- weeks of conservative treatment, the clinical re-evaluation requirement may be met with an office visit or could be “another form of meaningful contact,” such as a telephone call, e-mail, or any other form of messaging. Any re-evaluation, even a phone call, must be documented in the medical chart as well as any clinical improvement or lack thereof, and this information should be communicated to the RBM nurses when requesting the MRI.
Q: Are there any exceptions to the 6-week rule?
A: The following conditions do not require 6 weeks of conservative treatment:
• Certain acute injuries, for instance, a suspected rotator cuff injury after a fall.
• Avascular necrosis of the humeral head or asymptomatic loose bodies seen on the x-ray film
• Acute traumatic injury with inconclusive clinical exam and surgery planned
• Biceps long head rupture (and inability to visualize a “Popeye sign”)
• Pectoralis major/minor rupture
• Partial tendon rupture (excluding partial RCT or muscle belly strain/tears)
• Acromioclavicular separation or sternoclavicular dislocation
• Shoulder labral tear (guidelines support either MRI without contrast or MR arthrogram)
• Post-operative shoulder replacement surgery (CT or bone scans for loosening or suspected infection)
• Suspected osteochondral fracture with negative x-rays
• Suspected occult, stress or insufficiency fracture with negative x-rays
• Suspected delayed union or non-union of a fracture (simple or complex)
• Suspected osteomyelitis with negative or equivocal x-rays or
x-ray evidence of osteomyelitis if preoperative planning requires imaging.
• Suspected or known tumor/mass/cancer
• Suspected or known brachial plexus dysfunction
• Autoimmune disease (rheumatoid arthritis)
Q: Is an x-ray required for all shoulder conditions?
A: Virtually 100% of all imaging requests for MRI of the shoulder must demonstrate a past plain x-ray in order to be approved. There is no need to waste your office personnel’s time requesting a CT or MRI of the shoulder until a plain x-ray (taken since symptoms began, or if for chronic shoulder pain, in the last 3 months) has been performed. There are no exceptions.
Q: Coding for musculoskeletal pain or injuries is confusing. Sometimes I request a hand MRI and the RBM mistakes it for a humerus MRI. Can you simplify coding issues?
A: In post #29 I will explain the details of musculoskeletal imaging coding.
Lesson #27: Many requests for shoulder MRI are denied unnecessarily, and could be avoided if only providers were aware of the subtleties of the guidelines, especially the meaning and details of “6 weeks of conservative treatment.” Understanding these definitions will allow you to obtain prior authorization “right out of the gate.”