Diagnoses:

Lumbago; Spinal Stenosis of Lumbar Region

Summary:

The MRC Utilization Review Nurse Consultant recognized that the provider requesting the procedure is known to frequently request procedures that are not found to be medically necessary per Standards of Care under National Practice Guidelines. With this knowledge, the MRC UR Nurse Consultant requested additional records which were fully reviewed. After the case was reviewed and still determined to not be medically necessary, the records were forwarded to a Board Certified Specialty Physician peer who agreed with the determination. When the requesting surgeon was informed of the determination, a peer-to-peer conference was requested and again the determination for the procedure to be not medical necessary was upheld. The determination resulted in avoiding a non-medically necessary invasive surgery and a 3 to 4-day inpatient stay.

Cost Savings:


• Avoided spinal surgery professional fees: $ 38,641

• Avoided spinal surgery facility fees: $ 59,880

• Specialty Physician Review: ($ 462)

Total Cost Savings: $ 96,498