MHC uses InterQual ® criteria to assist in making medical necessity determinations. Many patients have high deductible health plans and will pay the entire costs of testing. InterQual ® criteria are evidencebased and designed to ensure appropriate utilization of medical procedures. Below are some general guidelines to ensure that your requests will meet medical necessity criteria.

1. For musculoskeletal issues, many criteria require evidence of failure of a trial of conservative therapy. Conservative therapy is usually defined as a three-week trial of prescription strength NSAIDs, six weeks of physical therapy and six weeks of activity modification.

2. Ordering an MRI on the first visit is often problematic.

3. Ordering an MRI because “the patient requests MRI of XXX” will likely result in a denial.

4. Ordering an MRI for a chronic problem with no changes in signs or symptoms will often result in a denial of coverage. Chronic back pain, neck pain and headaches are classic examples.

5. Many criteria require that a plain film of the area be done with results available before proceeding to an MRI. If the plain film has findings that explain the complaint, the MRI will be denied. Osteoarthritis of the knee is a common example. Pain in the knee. OA on plain film. No other issue. MRI of knee ordered. This will be denied if no other issues.

6. Ordering the plain film and MRI at the same time with plain film. Result not available will usually end up with a denial of coverage.

7. Make it clear in your assessment how the MRI result will alter your treatment decision. If you are not sure what is going on, getting a consult might be a good idea.

8. Getting an MRI as a requirement for getting an appointment with a specialist. If the clinical scenario does not meet criteria, it will not be approved. Consider using a different specialist or talk to your usual specialist if they have this as a “referral rule”.

9. Many criteria require that a lab diagnostic evaluation has been undertaken first. MRI of the pituitary for example. The pertinent lab results need to be available.

10. MRI of the Lumbar Spine is one of the most commonly ordered MRIs. The following are requirements for some of the commonly requested indications. a. Suspected lumbar disk herniation or foraminal stenosis. Requires radiculopathy plus either:

• Motor Deficit
  • Must have either severe motor weakness documented (scale 1-5) or
  • Less severe motor deficit which does not improve on re-evaluation

• Sensory Deficit (must have one of the following)
  • Severe pain (documented on scale of 1-10) and does not improve with conservative treatment for ≥ 3 days
  • Less severe pain refractory to NSAID and 6-week PT and activity modification
  • Paresthesias in a nerve root distribution which are worsening on re-evaluation
  • Suspected cauda equina – Document suspicion of cauda equina and symptoms consistent with cauda equina. Bilateral lower extremity weakness/numbness, bowel/bladder involvement, saddle anesthesia, sphincter tone.
  • Suspected Spinal Stenosis – document suspicion of spinal stenosis.
  • Document: Is pain worse with walking? Improved with forward flexion? Failure of conservative treatment?
  • Non-specific back pain with no neurologic deficits – Evidence does not support imaging.