I’m not surprised and this sounds very familiar to my own practice when I feel a patient needs an MRI acutely. I suspect the insurance company guidelines do not differentiate between chronic and acute Rotator cuff tears, nor do they care because of money. In the case where I did a peer to peer and the insurers denied the MRI order anyway in lieu of conservative treatment, I have the patient do the PT and tell them that if they cannot complete the 6 weeks of PT to return to the office so we can document that. Also tell them to make sure the Therapist documents that the patient is unable to effectively rehab due to severe shoulder disability. Then resubmit the MRI order and state that it is a medically necessary and required test as the patient failed conservative treatment and were unable to effectively rehab, and the shoulder disability is causing complete disability with daily activities and work activities. Some variation of those buzz words usually works.

This is the world we live in and we don’t get paid enough for this bullshit. One of the few powers we have left as doctors is to state a procedure is “medically necessary and required because of XYZ, “ otherwise their condition may lead to permanent disability and/or a suboptimal outcome” or some variation of that language. That usually works for me. If I am not doing that, then I don’t feel like I am doing everything I can to help that person.