MRI Preauthorization: Approval Criteria and Options If Denied

MRI preauthorization is a system used by insurance carriers that often creates problems for patient care, primarily by delaying diagnosis and treatment. A major issue is the secrecy surrounding the approval criteria, leaving healthcare providers and patients at a disadvantage. The article shares some decoded criteria, including the requirement that patients must complete six weeks of unsuccessful conservative care before a scan is typically approved. Other factors that warrant scanning include physical signs of disc radiculopathy or stenosis, such as positive SLR or slump tests, evidence of progressive neurological loss like diminished reflexes or muscle atrophy, and relevant abnormal findings on existing imaging. Obtaining a CT scan first may sometimes be easier and provide support for an MRI.When preauthorization is denied, the doctor can request a peer-to-peer phone conference with a carrier representative, although these discussions should focus on documentation, as carrier rules lack emotion. If the scan is denied again after the peer-to-peer conference, a crucial option is to get the patient involved. As it's their insurance, they can call the carrier to make their case, but the author cautions against suggesting this before a denial occurs to avoid confusion. This current era contrasts with the early days of managed care when carriers sometimes encouraged scans to validate claims they ultimately had to pay.