GQ Corner

Q. Rule 134.600(p)(8) provides that a repeat individual diagnostic study, per the medical fee guidelines, requires preauthorization. What exactly does “individual diagnostic study” mean? In other words, we know that a second MRI to the shoulder would require preauthorization. However, should the injured worker undergo a CT to the shoulder, and then later, the treating doctor requests an MRI of that shoulder, does the second diagnostic require preauthorization, or does it not because it’s the first MRI?

A. While a repeat study certainly requires preauthorization, that does not mean that all initial studies do not. Most CT scans and MRIs are not recommended by the ODG except under specific criteria and if they are not, then preauthorization is required. But, if the ODG says that both an MRI and a CT are recommended, then neither would require preauthorization. But, of course, in most instances, the ODG does not recommend both. So the second would likely require preauthorization.

The way to handle this is to (1) never advise the provider whether preauthorization is required; (2) submit through preauthorization any request (and insist that your URA process it); and (3) have your URA retrospectively review any bill for a service that was not preauthorized, and raise as a second defense the lack of preauthorization if the URA determines that the study was not medically necessary and inconsistent with the ODG.