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 with 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 knee 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 any of the following:
• rest, ice, compression and elevation (RICE) especially for acute injuries
• non-steroidal anti-inflammatory drugs
• narcotic and non-narcotic analgesics
• oral or injectable corticosteroids
• chiropractic treatments
• visco-supplementation injections
• a provider-directed home exercise program
• physical and/or occupational therapy
• immobilization by splinting/casting/bracing
• medical devices (crutches, metal braces, orthotics, 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: Yes. Traumatic injuries to the knee are exempt if specified criteria are met. For example, the guideline for immediate MRI for suspected meniscus tear requires only a recent x-ray if 2 of the following 4 criteria are present:
o Positive McMurray test,
o History of a twisting acute injury of the knee,
o inability to fully extend knee/locked knee,
Other exceptions to the 6-week rule include:
• If x-ray demonstrates avascular necrosis of the distal femur.
• If asymptomatic loose bodies are seen on plain film.
• If clinical exam is inconclusive and surgery is being planned for any acute traumatic injury.
• Pre-op planning for a complete rupture of the distal quadriceps tendon or the patellar ligament/tendon.
• Partial tendon rupture excluding belly strain/tears.
• Knee or patella dislocation
• Post-operative knee replacement surgery (CT or bone scans for loosening or suspected infection)
• Suspected osteochondral fracture with negative x-rays
• Complex fracture
• Suspected occult, stress or insufficiency fracture with negative x-rays
• Suspected delayed union or non-union of a fracture
• Suspected osteomyelitis with negative or equivocal x-rays
• X-ray evidence of osteomyelitis if preoperative planning requires imaging.
• Suspected or known tumor/mass/cancer
• Autoimmune disease (rheumatoid arthritis)
Q: Is an x-ray required for all knee conditions?
A: Virtually 100% of all imaging requests for MRI of the knee 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 knee until a plain x-ray (taken since symptoms began, or if for chronic knee 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 knee MRI and the RBM mistakes it for an ankle MRI. Can you simplify coding issues?
A: In the next post I will explain the details of musculoskeletal imaging coding.
Lesson #28: Many requests for knee 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.”