Always Provide Justifications for Medical Treatment Requests

Douglas Benner, M.D.
Chief Medical Officer, EK Health Services, Inc.


Reminder: When making medical treatment requests, it is essential to explain WHY a particular treatment is requested. This will help the Claims Administrator approve the request at their level, or facilitate approval by a UR organization if the request is elevated to them for review.

For medications, it is useful to document the indication or reason the patient needs the medication. For example, if a proton pump inhibitor (PPI) is being given with a NSAID, notate what increased risk factors your patient has necessitating the PPI in their case.

For imaging, when a study is being requested document what factors in your patient indicate the medical necessity for the study. This is especially important if the study is being done earlier than the standard guideline recommendations. For example if ordering a MRI of lumbar spine early in a case, document if you have a concern about possible cancer, infection or deteriorating neurological function. Then an early MRI is more likely to be approved.