MRI Preauthorization: Approval Criteria and Options If Denied

In 1993, a patient I had diagnosed with a lumbar disc problem discontinued care after only a few weeks of treatment. When he left, his bill totaled slightly over $800.

A few weeks after filing his claim, the insurance carrier demanded that the patient get a lumbar MR scan. The carrier wanted proof the patient had a disc problem before paying the claim. I contacted the patient, and he refused to have the scan.

However, in 1993, managed care was still relatively new, and he did not have a managed care policy. I did not have to accept what the carrier paid; there were no predetermined write-offs, and I could balance-bill the patient. He had to have the MR or pay the $800.

The patient got the scan, and the disc pathology was confirmed. The carrier spent $1,300 on the scan to avoid an $800 bill and paid the claim.

This experience occurred several times during the early years of my practice. Thankfully, it stopped after carriers realized they were spending a lot of money trying to avoid paying claims they usually ended up paying anyway.

We are now practicing in an era in which carrier measures regarding MR scans have reversed. Carriers went from encouraging them to avoiding them as often as possible, primarily through preauthorization processes.

Approval Criteria

Preauthorization is problematic for patient care because it often delays diagnosis and treatment. The primary reason for the delays is the secrecy of the process. Carriers do not divulge the criteria for scan approval, leaving health care providers and, ultimately, patients at a disadvantage.

With experience and a little help from a friendly peer-to-peer reviewer, I have decoded a few items of the approval criteria and wish to share them.

• Patients must complete six weeks of conservative care without success before a scan is approved. Conservative care can be chiropractic care, physical therapy or both. Note that six weeks of care is not always the six weeks immediately before the scan request. Intermittent care over previous months can be pieced together to count.
• Scanning is warranted when physical signs of disc radiculopathy or stenosis are present. Positive results for Bakody’s, abducted arm sign, and upper extremity tension tests substantiate scanning for cervical disc/radicular pathology. A positive SLR test (30-70 degrees of femoral flexion) or a positive slump test substantiates scanning for lumbar disc/radicular pathology. Scanning for stenosis is validated when bicycle or shopping cart signs are positive. Approval is more likely when multiple positive physical tests or signs are present.
• Progressive neurological loss validates scanning. The patient may exhibit diminished reflexes, dropped foot, muscle atrophy, or other signs and symptoms.
• Relevant abnormal findings on existing imaging (recent or previous) can necessitate scanning. This can be routine imaging, CT scans, etc.
• Obtaining a CT scan is easier than obtaining an MR scan, so obtaining a CT first is helpful. This may provide the diagnostic information necessary for the case and/or provide additional support for obtaining an MRI. Look at previous CT scans taken for non-spinal complaints. CT of the abdomen and chest show the spine and may provide additional information to support MR scanning.

When Authorization Is Denied

Even with documentation of the above factors, a carrier may not authorize a scan. In this case, the doctor who ordered the scan and a doctor working for the insurance carrier may discuss the scan during a peer-to-peer phone conference.

Peer-to-peer conferences generally go well, but they can also go poorly. A standard mistake doctors make when contesting denials is approaching the matter from an emotional standpoint. Doctors have empathy and concern for their patients. They know their patients and understand their stories. They want insurance carriers to understand these stories.

Regrettably, carrier rules lack emotion, and carrier representatives are not allowed to perform their jobs from an emotional standpoint. Additionally, carrier employees have little authority to make exceptions in most processes. Doctors, we are playing in a contest in which documentation wins the day.

When a scan is denied in the preauthorization process and again during a peer-to-peer conference, there is an option available that might influence the carrier. Get the patient involved. It is their insurance, and they can call the carrier to make their case. Patient calls can work well, but I offer one caution: Do not suggest this to the patient until after denials are encountered.

I once told a patient that calls from the insured can push authorization through. The patient called the carrier immediately after her appointment from the office parking lot, before I could initiate the order. With no order in the system, the carrier had no idea what the patient was talking about, which created a great deal of confusion and further complicated the preauthorization.