Diagnoses:

Displacement of Lumbar Intervertebral Disc without Myelopathy; Lumbago

Summary:

A request was made by the provider’s office for spinal surgery for this participant. The MRC UR Nurse Consultant reviewed the clinical documents. She found the participant’s records did not include a referral for surgical intervention. In speaking directly with the provider, it was also learned that there was no fracture and no instability. The direct conversation with the provider confirmed that the request did not meet medical necessity and the surgery was denied. When the participant learned of the determination, she requested additional assistance and recommendations which the Nurse Consultant was able to provide based on her nursing education and background. The patient agreed to follow the recommendations and appreciated the information instead of undergoing another surgical procedure.

Cost Savings:


• Avoided spinal surgery professional fees: $ 34,104

• Avoided spinal surgery facility fees: $ 59,000

• Specialty Physician Review: ($ 440)

Total Cost Savings: $ 92,664