Joint and back pain lead to inappropriate referrals

Two top 10 lists compiled by utilization management company CareCore National show that requests for musculoskeletal and spinal MRI account for five of the 10 leading indications denied by the company in 2004.

One top 10 list (see table) identifies inappropriate procedures that would have generated the highest unnecessary medical costs had they not been avoided through a preauthorization review, according to chief medical officer Dr. Michael Komarow.

The table confirms suspicions about the high cost of inappropriate spinal and musculoskeletal MR scans, Komarow said. Most denials for spinal or joint MRI occur because of failures to comply with the accepted waiting period before imaging.

"Many patients, with a little time and physical therapy, will improve, and their symptoms will go away without intervention. There seems to be impatience on the part of the physician and the patient to do the imaging," he said.

CareCore received more than 67,000 requests for noncontrast MRI of lower extremity joints (CPT code 73721). It refused more than 6000, or about 9%, of the requests, pushing that indication to the top of the list in terms of rejected imaging volume. The firm also turned down about 9% of physician requests for lumbar and cervical spine MRI performed without contrast (CPT codes 72148 and 72141, respectively) and about 10% of MR upper extremity studies without contrast (73221).

Three CT indications rank among the top 10 high-volume generators of denials: CT thorax with contrast (71260) and without it (71250) and CT of the maxillofacial area-sinuses (70485). Requests for noncontrast CT of the thorax for patients with chronic cough are often rejected because a prerequisite chest x-ray has not been performed, said Dr. Shelley Weiner, senior medical director at CareCore.

CT of the maxillofacial area is often inappropriately prescribed for patients with chronic and allergic sinusitis and allergic rhinitis. Some physicians do not understand that CT is an option only when surgery is under consideration, she said.

Another list addresses procedures that were most frequently denied, usually because referring physicians do not understand these new technologies or the practice criteria that govern their use, Komarow said.

With a 38% denial rate, CT angiography of the chest ranks as the most frequently rejected set of imaging procedures. That category includes CTA for suspected coronary artery disease, a new application that has produced encouraging results in early clinical trials. But no consensus has emerged for its use in community-based practice.

The proper role of breast MRI also is misunderstood, Weiner said. Although multicenter trials are still in process, the medical community agrees that breast MR has value as an adjunct to mammography for augmented breasts and as a screening test for women with a high genetic risk of cancer. Questions remain, however, regarding its appropriateness for determining whether a biopsy should be performed after an indeterminate mammogram or for routine screening of dense breasts.

The top 10 lists were compiled from 840,000 requests for MR and CT imaging studies phoned into CareCore's precertification center in Wappingers Falls, NY, last year. The firm contracts with private healthcare insurers, mainly in the northeastern U.S., for imaging precertification services covering about six million lives. CareCore's overall denial rate in 2004 was 6%.

DENIAL RATE BY VOLUME

Description of CPT code Number of requests Percent denied

MRI lower extremity joint w/o contrast 67,381 9.1

MRI lumbar spine w/o contrast 59,702 9.4

MRI cervical spine w/o contrast 35,152 9.6

MRI upper extremity joint w/o contrast 32,108 10

CT maxillofacial area (sinuses) 32,250 6.4

CT thorax w/o contrast 34,366 5

MRI head w/contrast 11,823 14

MRI lower extremity joint w/o contrast 10,113 15.6

MRI head w/ and w/o contrast 26,704 5.1

CT thorax w/contrast 36,259 3.7

Source: CareCore National