Oct 25th 2018

The 8 Most Common Inappropriately Ordered Tests — and Why They're Being Denied

​There are an abundance of tests that can help diagnose a patient's symptom-causing condition, and some can even help discover troublesome uncommon conditions. However, some tests can also produce erroneous results known as "false positives," which might lead to unnecessary additional testing and sometimes the treatment of benign conditions. In this situation, patients and providers may prefer to take a "better safe than sorry" approach and seek to obtain as much information as possible through laboratory and radiologic testing. 

Many of the common tests are frequently ordered inappropriately, i.e., without an indication supported by scientific evidence. To help navigate these challenges, we've compiled a list of the eight most common inappropriately ordered tests (from least common to most common), with explanations on when they're appropriate, and when they may be denied because they're not the best treatment option.

#8 Echocardiogram

What is it?

Also known as echocardiography or a cardiac ultrasound, this test uses ultrasound waves to allow the doctor to see the heart muscle and its structures. 

What does it do?

The most common reasons for an echocardiogram are to see if there is damage to the muscle, a problem with the functioning of the heart, or issues with the valves of the heart. Symptoms caused by such issues can include shortness of breath, palpitations, or chest pain. Sometimes, the patient is asked to walk on a treadmill to stimulate the heart before the images are taken; this is known as a stress echocardiogram. 

Why is it denied coverage by healthplans? 

An echocardiogram is an extremely useful test. It has simplified the diagnosis and assessment of many cardiac conditions. Because an ultrasound is easy to perform and does not subject the patient to radiation exposure, an echocardiogram is frequently performed inappropriately; in fact, many are performed routinely on an annual basis in patients with a history of heart disease who are not experiencing new or worsening symptoms. There is good evidence, and it is generally agreed upon, that these routine echocardiograms are of limited to no value. 

Risk: A false positive result may lead to additional downstream testing.

#7 MRI of the head 

What is it?

An MRI will produce a picture of the brain and brain stem to explore possible abnormalities. With/without contrast refers to the use of contrast material to highlight potential problems. 

What does it do?

This test can help isolate and identify the source of bleeding from a concussion or hemorrhage, and can locate or identify cysts, tumors, or damage due to strokes. An MRI of the head can also be used to check on the ongoing effectiveness of a mechanism (like a shunt) inserted during a previous medical procedure. 

Why is it denied coverage by healthplans? 

The indications for these tests can be complex and may be subject to what is called a medical necessity review to assess the appropriateness of the request. Coverage for the test by the health plan is usually determined by the individual's health plan policies, which may recommend more appropriate alternative measures. And often these procedures can be performed in freestanding imaging centers rather than in outpatient hospital settings, at less expense. 

Risks: Interference with pacemakers or other internal devices; magnetic pull that can tear out aneurysm clips, piercings, or shrapnel; unnecessary surgery. In addition, if performed with contrast: kidney damage, allergic reaction to contrast, or deposit of IV contrast that does not always leave the brain. 

#6 CT scan of the chest

What is it?

This is a diagnostic imaging test that uses X-rays to help assess the structures within the chest. Intravenous contrast can be used to help highlight vascular structures. 

What does it do?

A CT scan of the chest produces images of the structures within the chest such as the lungs, heart, and aorta. It can aid in the identification of abnormalities such tumors, aneurysms, infection, or fluid collections. 

Why is it denied coverage by healthplans? 

A CT scan is a "hi-tech" X-ray. It is a more extensive test than is generally necessary for common symptoms such as a cough, shortness of breath, or chest pain. Requests are inappropriate because preliminary tests have not been performed first (e.g., an X-ray). 

Risks: Kidney damage; allergic reaction to contrast; exposure to radiation.

#5 CT scan of the abdomen and pelvis

What is it?

This is a diagnostic imaging test that uses X-rays to help in the assessment of the structures and organs within the abdomen and pelvic areas, such as the stomach, liver, kidneys, or colon. It is helpful in isolating abnormalities in the stomach, liver, kidneys, colon, and pelvis. Intravenous contrast can be used to help highlight vascular structures. 

What does it do?

This test produces images of the structures within the abdomen and pelvis and can be used to identify and diagnose disorders such as cancers, kidney stones, or inflammation due to Crohn's disease. A CT scan of the abdomen and pelvis can also help in identifying and diagnosing infections, abscesses, or fluid collections. 

Why is it denied coverage by healthplans? 

Abdominal and pelvic pain are common symptoms in patients presenting to a primary care provider, urgent care, or emergency department. The most common reason these tests are denied is that more appropriate initial studies are not done first (such as an ultrasound or an X-ray) to exclude common causes of a patient's complaints. These initial studies are not only simpler and less costly but also likely to provide answers to the problem. An ultrasound is generally the most appropriate test for assessing pain that may be associated with gallstones or kidney stones. Ultrasound exams do not generally require intravenous contrast and there is no associated radiation exposure. 

Additionally, the diagnosis of many of these conditions requires scanning of only one area, the pelvis or abdomen, not both. 

Risks: Kidney damage; allergic reaction to contrast; exposure to radiation.

#4 Nuclear stress test

What is it?

This is a complex test that is used to assess symptoms of heart disease that may be due to blockage of the blood vessels to the heart muscle. According to the Mayo Clinic, a nuclear stress test "…uses radioactive dye and an imaging machine to create pictures showing the blood flow to your heart. The test measures blood flow while you are at rest and are exerting yourself, showing areas with poor blood flow or damage in your heart." The test can take up to 4 hours to perform. 

What does it do?

A nuclear stress test is most commonly used to diagnose coronary artery disease in patients with complaints of chest pain. 

Why is it denied coverage by healthplans? 

This test is often used more frequently than is medically necessary. The most common inappropriate requests are in patients who are at low risk for heart disease, and in patients with heart disease who are not having any new or worsening symptoms. Additionally, other less complex types of stress tests, i.e., that do not involve radiation or IVs and take less time can be used to assess a patient's symptoms. 

Risks: Allergic reaction to contrast; IV site complications; radiation exposure. 

#3 MRI of the cervical spine

What is it?

This test creates an image of the spine in the neck to identify possible issues with structures such as bones, soft tissue, tumors, or herniated discs. 

What does it do?

This test is most commonly performed when there are potential issues in the neck region of the spine, causing symptoms such as neck pain or arm problems (e.g., pain or weakness). An MRI of the cervical spine is usually performed after conservative treatments such as anti-inflammatory medications or physical therapy have been unsuccessful in mitigating the symptoms. It can also help highlight spinal defects or problems after trauma or infection or in cases involving abnormal curvature of the spine. 

Why is it denied coverage by healthplans? 

Similar to an MRI of the head (#7), the indications for this test can be complex and therefore may be subject to a medical necessity review to assess the appropriateness of the request. Coverage for the test is according to the individual's health plan policies, which may recommend more appropriate conservative therapy first.

Risks: Interference with pacemakers or other internal devices; magnetic pull that can tear out aneurysm clips, piercings, or shrapnel; unnecessary surgery. In addition, if performed with contrast: kidney damage, allergic reaction to contrast, or deposit of IV contrast that does not always leave the brain. 

#2 MRI of the lower extremity — joint

What is it?

This test creates an image of the joints of the leg—including the hip, knee, ankle, and foot—to isolate and define possible issues. 

What does it do?

This test is commonly used to diagnose soft-tissue damage in the leg, such as damage to muscles, ligaments, or cartilage. This MRI is also used to identify tumors that may be causing symptoms such as pain or instability, to determine if surgery is necessary. The most common use for this MRI is to check the knee for cartilage and ligament tears.

Why is it denied coverage by healthplans? 

Acute issues with the joints of the lower extremities are common and are usually first treated conservatively with rest, ice, and anti-inflammatories—and later, perhaps, with physical therapy. Appropriate use of this test is generally reserved for issues that have not resolved after conservative treatment and to help decide if surgery may be necessary. It is important to note that even if there is a cartilage problem, it does not necessarily require surgery.

Risks: Interference with pacemakers or other internal devices; magnetic pull that can tear out aneurysm clips, piercings, or shrapnel; unnecessary surgery. In addition, if performed with contrast: kidney damage, allergic reaction to contrast, and deposit of IV contrast that does not always leave the brain. 

#1 MRI of the lumbar spine 

What is it?

This test creates an image of the lower-back region of the spine called the lumbosacral spine, which includes the lumbar region (vertebrae L1 through L5), the sacrum, and the coccyx (better known as the tailbone). An MRI of the lumbar spine is used to isolate and define potential issues with the structures in this area such as discs, bones, and soft tissue. 

What does it do?

This test helps to decipher whether there is a problem beyond a simple muscle spasm, such as a slipped disc, tumor, or infection, causing pain that would require surgical intervention. 

Why is it denied coverage by healthplans? 

Low back pain is one of the most common complaints of people who see a doctor. It might result from sitting on the floor, twisting our backs, or taking on a weekend landscaping project. The great majority of low back pain is muscular in nature and due to overexertion or from contraction of the muscles due to inactivity (especially from prolonged sitting associated with desk jobs). Low back pain has become so common that entire product lines have been developed because of it, such as standing desks and ergonomic chairs. Most low back pain can be treated with rest and physical therapy, which involves stretching and strengthening exercises. An MRI is not necessary for the majority of low back pain issues. What's more, it can show incidental benign findings, sometimes called "incidentalomas," that can lead to added tests and procedures. Finally, a provider can usually get a good assessment as to the origin of the pain from a history and physical exam. 

However, if there are symptoms such as leg weakness or changes in bowel or bladder function, an MRI of the lumbar spine can be useful to decipher whether there is a problem beyond a simple muscle spasm, causing pain that would benefit from surgical intervention.

Risks: Interference with pacemakers or other internal devices; magnetic pull that can tear out aneurysm clips, piercings, or shrapnel; unnecessary surgery. In addition, if perfomed with contrast: kidney damage, allergic reaction to contrast, or deposit of IV contrast that does not always leave the brain. 

How to Avoid a Prior Authorization Stop 

The important thing to remember when considering a test that requires prior authorization is that a denial does not always mean no test, but that the requested test may not be the best test for the situation. 

One of the primary functions of the prior authorization process in the healthcare system is to prevent tests which won't give answers; or, ones which may be repetitive or redundant to some other procedure. Such tests can be time-consuming, waste resources, and increase the financial burden on the patient. eviCore provides a comprehensive manual of guidelines to assist in the evaluation of a patient's condition, which includes the appropriate indications for testing. These guidelines are developed from research and data and are based on medical journals, research, and clinical practice. Contrary to many prior-authorization guidelines, eviCore guidelines are driven by the patient's presenting medical condition rather than by imaging CPT (procedure) codes. 

When planning next steps, patients can be proactive and take measures to help minimize the potential for denial of a request: 

  • Get a clear picture of what the test will be seeking by asking why it's been ordered. 
  • Before you schedule the appointment for the scan, contact your health insurance provider to find out the details of your plan's coverage for testing, to help minimize costs. (This isn't necessary if you've already been contacted by your prior authorization provider.) 
  • Find out where your doctor suggests you go for your test—some facilities are much more expensive than others, for the same tests. Your prior authorization provider can help find the most affordable care nearby. 

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