What's the best way to get a pre-authorization approved for a lumbar spine Magnetic Resonance Imaging (MRI)?

From the Guidelines

To get a pre-authorization approved for a lumbar spine MRI, ensure that your healthcare provider documents a clear medical necessity, including failed conservative management and specific symptoms or red flags, as supported by the most recent guidelines from the American College of Radiology 1. The most effective approach is to have your physician thoroughly document your symptoms, such as severe back pain, radiculopathy, or neurological deficits, previous treatments attempted, including physical therapy, medications like NSAIDs or muscle relaxants, and their durations, and why conservative management has failed. Some key points to include are:

• Red flag symptoms like bowel/bladder dysfunction, progressive weakness, or suspected serious pathology
• Specific details on what the MRI is intended to diagnose, such as disc herniation, spinal stenosis, or tumor
• How the findings from the MRI would change your treatment plan Before submitting, verify that your diagnosis codes (ICD-10) accurately reflect your condition and match insurance criteria, as emphasized in recent studies 1. Follow up with both your provider's office and insurance company within 3-5 business days if you haven't received a response. Insurance companies typically approve MRIs when they see evidence that the imaging is medically necessary and will influence treatment decisions, rather than being ordered prematurely before conservative measures have been tried, a principle supported by the American College of Physicians and the American Pain Society 1. It's also important to note that imaging is not typically warranted for acute low back pain without red flags or prior management, as stated in the ACR Appropriateness Criteria 1. However, for patients with subacute or chronic low back pain who have failed conservative therapy, MRI of the lumbar spine is the initial imaging modality of choice, as it accurately depicts lumbar pathology and can identify potential actionable pain generators 1.

From the Research

Best Practices for Pre-Authorization Approval

To increase the chances of getting a pre-authorization approved for a lumbar spine MRI, consider the following:

• Ensure that the request is appropriate and follows evidence-based guidelines, as seen in the study 2, which developed a combined imaging appropriateness checklist for lumbar spine MRI and CT.
• Provide clear and detailed information about the patient's condition and the reason for the MRI request, as suggested by the study 3, which found that nearly 50% of patients meeting AHCPR guidelines underwent an MRI.
• Verify the patient's insurance coverage and any specific requirements for pre-authorization, as highlighted in the study 4, which found that Medicaid insurance status was associated with a higher likelihood of denial for MRI prior authorization requests.

Reducing Inappropriate Lumbar Spine MRI Requests

To reduce inappropriate lumbar spine MRI requests, consider the following:

• Implement educational sessions for clinicians on evidence-based guidelines for imaging, as seen in the study 5, which found that clinician education resulted in a reduced number of MRI lumbar spine studies performed for uncomplicated low back pain.
• Use tools such as the ACR's Radiology Support, Communication and Alignment Network (R-SCAN) program to evaluate and improve the appropriateness of MRI orders, as described in the study 5.
• Develop and implement a combined imaging appropriateness checklist, as seen in the study 2, to reduce the complexity associated with individual checklists and facilitate imaging appropriateness.

Improving the Prior Authorization Process

To improve the prior authorization process, consider the following:

• Identify and address barriers to successful pre-authorization, as seen in the study 6, which found that educational training and process changes resulted in a reduction in denied charges.
• Implement process changes to reduce the burden of prior authorization, such as streamlining the request process or providing clear guidelines for clinicians, as suggested by the study 6.
• Monitor and evaluate the effectiveness of the prior authorization process, as seen in the study 4, which found that the low denial rate of initial prior authorization requests underscored the questionable utility of the prior authorization process.