Is There Utility to Requiring Spine MRI Pre-authorizations? Pre-authorizations

Kebaish, Kareem J.; Galivanche, Anoop R.; Mercier, Michael R.; Varthi, Arya G.; Rubin, Lee E.; Grauer, Jonathan N.

doi:10.1097/bsd.0000000000001422

Cited by 3 publications

(3 citation statements)

References 7 publications

(15 reference statements)

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“…Prior authorizations have increased in recent years, adding a significant burden to the medical system. Other specialties have looked at the burden, utility, and ethics of prior authorization [22][23][24][25][26][27]. Within orthopedic surgery, though, there are few studies reviewing its impact on clinical care.…”

Section: Introductionmentioning

confidence: 99%

“…Within orthopedic surgery, though, there are few studies reviewing its impact on clinical care. Kebaish et al [ 27 ] retrospectively reviewed all spine MRIs ordered at a single institution and found that 85% required prior authorization, 10% required peer-to-peer review, and, of the 18% of MRI orders initially canceled or denied by this process, 77% were completed within three months. Only 85 of 2,480 orders were never done [ 27 ], raising concerns over the overall utility and ethics of this process.…”

Section: Introductionmentioning

confidence: 99%

“…Kebaish et al [ 27 ] retrospectively reviewed all spine MRIs ordered at a single institution and found that 85% required prior authorization, 10% required peer-to-peer review, and, of the 18% of MRI orders initially canceled or denied by this process, 77% were completed within three months. Only 85 of 2,480 orders were never done [ 27 ], raising concerns over the overall utility and ethics of this process. One of the main reasons for denial of the MRI in orthopedics is often the lack of six weeks of conservative care in the last 12 weeks.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Accuracy of Clinical Suspicion for Rotator Cuff Tears by Orthopedic Surgeons When MRI Was Ordered on Initial Visits: Should Physical Therapy Be Mandated by Insurance Before MRI?

Gutowski,

Pohl,

Stern

et al. 2024

Cureus

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Introduction: Insurance companies often mandate six weeks of physical therapy (PT) prior to approving MRIs for patients with atraumatic rotator cuff (RTC) tears. While this is designed to limit unnecessary imaging orders, it can increase healthcare costs and delay diagnosis and surgery. This study investigated the incidence of full-and partial-thickness tears when an MRI was ordered at the time of initial consultation for shoulder pain by an orthopedic provider.Methods: A retrospective review of patients who had an MRI ordered upon initial orthopedic consultation for chronic shoulder pain was conducted. The primary outcome measured was the presence of RTC tears as determined by the MRI report. The cost of six weeks of PT versus the cost of immediate MRI in these patients was collected from our institution's financial database. ANOVA, independent T-test, and chi-square test were used to analyze the differences between groups.Results: A total of 365 patients were included. There were no significant differences in demographics between patients with full, partial, or no tears, with the exception that patients with full-thickness tears were older. Specifically, 43.0% had a full-thickness tear, 24.7% had a partial-thickness tear, and 32.2% had no tear on MRI. A total of 56.1% of the full-thickness tears proceeded to surgery. The cost of an upper extremity MRI without contrast averages $2,268, while two sessions of PT per week for six weeks totals $2,328.Discussion: Over 67% of MRI orders yielded a positive finding of an RTC tear and remained at 67.2% in the absence of a history of conservative treatment, validating a specialist's clinical suspicion for an RTC tear and indication for MRI. Pre-MRI PT to satisfy insurance requirements may therefore delay intervention and increase healthcare costs when an orthopedic provider believes an MRI is warranted for clinical decisionmaking.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Accuracy of Clinical Suspicion for Rotator Cuff Tears by Orthopedic Surgeons When MRI Was Ordered on Initial Visits: Should Physical Therapy Be Mandated by Insurance Before MRI?

Gutowski,

Pohl,

Stern

et al. 2024

Cureus

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The hidden value of MRI: modifying treatment decisions in C-spine injuries

Rutsch,

Schmaranzer,

Amrein

et al. 2024

Scand J Trauma Resusc Emerg Med

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Background data Computed Tomography (CT) is the gold standard for cervical spine (c-spine) evaluation. Magnetic resonance imaging (MRI) emerges due to its increasing availability and the lack of radiation exposure. However, MRI is costly and time-consuming, questioning its role in the emergency department (ED). This study investigates the added the value of an additional MRI for patients presenting with a c-spine injury in the ED. Methods We conducted a retrospective monocenter cohort study that included all patients with neck trauma presenting in the ED, who received imaging based on the NEXUS criteria. Spine surgeons performed a full-case review to classify each case into “c-spine injured” and “c-spine uninjured”. Injuries were classified according to the AO Spine classification. We assessed patients with a c-spine injury detected by CT, who received a subsequent MRI. In this subset, injuries were classified separately in both imaging modalities. We monitored the treatment changes after the additional MRI to evaluate characteristics of this cohort and the impact of the AO Spine Neurology/Modifier modifiers. Results We identified 4496 subjects, 2321 were eligible for inclusion and 186 were diagnosed with c-spine injuries in the retrospective case review. Fifty-six patients with a c-spine injury initially identified through CT received an additional MRI. The additional MRI significantly extended (geometric mean ratio 1.32, p < 0.001) the duration of the patients’ stay in the ED. Of this cohort, 25% had a change in treatment strategy and among the patients with neurological symptoms (AON ≥ 1), 45.8% experienced a change in treatment. Patients that were N-positive, had a 12.4 (95% CI 2.7–90.7, p < 0.01) times higher odds of a treatment change after an additional MRI than neurologically intact patients. Conclusion and relevance Our study suggests that patients with a c-spine injury and neurological symptoms benefit from an additional MRI. In neurologically intact patients, an additional MRI retains value only when carefully evaluated on a case-by-case basis.

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Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved

Imam,

Zaifman,

Bassora

et al. 2024

Orthopedics

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In the event of prior authorization denial, physicians may request peer-to-peer review, which may delay treatment and increase administrative burden. The purpose of this study was to quantify the approval rate of peer-to-peer review and evaluate its efficiency in the context of advanced imaging use in an orthopedic practice. Patients at a single outpatient orthopedic clinic initially receiving an insurance denial for computed tomography or magnetic resonance imaging requiring peer-to-peer review from March to December 2022 were prospectively enrolled. Characteristics of the request, peer-to-peer review, and the reviewer and dates in the process were collected. If the study was approved after peer-to-peer review, the date of the imaging study and brief results were recorded. A total of 62 denials were included. One denial was approved prior to peer-to-peer review. Fifty-eight (of 61, 95.1%) reviews were approved, of which 51 (of 58, 87.9%) studies were completed by patients. Reviewers were always physicians (61 of 61, 100%), but of those whose specialty was known, none were orthopedic surgeons. Forty-four of 61 (72.1%) reviewers reported reviewing clinical notes in advance. The median number of days from visit to peer-to-peer review was 9.0 (interquartile range, 7.0–13.25). The median number of days from visit to imaging center appointment was 13.5 (interquartile range, 9.0–20.75) for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis. In an orthopedic specialty practice, almost all peer-to-peer reviews were approved, with the majority of the completed studies confirming the suspected diagnosis. Thus, patient care was delayed. Reform is crucial to improve the efficiency of the review process, especially in light of additional administrative and financial burden. [ Orthopedics . 202x;4x(x):xx–xx.]

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Is There Utility to Requiring Spine MRI Pre-authorizations? Pre-authorizations

Abstract: A retrospective cohort study of a patient undergoing treatment at a single institution's Spine Center.Objective: The current study assessed the rates and eventual disposition of pre-authorizations required before spine MRIs are ordered from an academic spine center.

Cited by 3 publications

References 7 publications

Accuracy of Clinical Suspicion for Rotator Cuff Tears by Orthopedic Surgeons When MRI Was Ordered on Initial Visits: Should Physical Therapy Be Mandated by Insurance Before MRI?

Accuracy of Clinical Suspicion for Rotator Cuff Tears by Orthopedic Surgeons When MRI Was Ordered on Initial Visits: Should Physical Therapy Be Mandated by Insurance Before MRI?

The hidden value of MRI: modifying treatment decisions in C-spine injuries

Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved

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