Download Thoracic Spine MRI Imaging Questionnaire

Thoracic Spine MRI Imaging Questionnaire
1. INSTRUCTIONAL NOTE: Advanced Imaging UR program applies ONLY to STATE FUND WORKERS’
compensation claims. For authorization of services pertaining to Self-Insured claims, please contact the
injured worker’s employer or the third party administrator.
2. (Mandatory) DISCLAIMER: This is a guideline-based review that will result in a recommendation only.
L&I must make the final determination of payment based on legal claim validity. Approval should occur
within 24-48 hours.
Acknowledge
3. SECTION A: ACUTE THORACIC BACK PAIN (ONSET W/IN PAST 6 WEEKS): MRI without contrast
unless specified otherwise:
Yes
No
4. A1 - If Yes, select one:
Bilat neuro weakness in low extrem by PE
Focal pain follow fall from ht or trauma
Bladder/bowel dysfunction follow trauma
Sx compatible w/focal radiculopathy
Infection: MRI w/o, w/contrast (go to 7)
Hx of cancer w/new pain (go to 6)
Suspicion of cancer w/new pain (go to 6)
Low velocity trauma, >70yrs (go to 8)
Osteoporosis, > 70yrs (go to 8)
NA
5. A2 – Is there History or suspicion of cancer with new onset of thoracic pain?
Yes
No
6. A3 – If Yes, History or suspicion of cancer criterion can be met if any TWO of the following are present
(select two):
Age over 50
Failure to improve after one month
Unexplained weight loss
NA
7. A4 – If answer is Infection: MRI without and with contrast, select one:
Elevated sedimentation rate
Fever
Immunosuppression (e.g. steroid use)
IV drug use
Known bacteremia
Suspicion of systemic or spinal infection
NA
8. A5 – If answer is Low velocity trauma OR osteoporosis, AND/OR age > 70 years, select one:
Vertebral compression on x-ray
Other fractures
NA
Thoracic Spine Imaging updated 02/09/2011
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9. SECTION B: SUBACUTE THORACIC BACK PAIN > 6 WEEKS, MRI W/O CONTRAST. Did the patient
have MEDICAL/CONSERVATIVE CARE? If No, stop and submit the questionnaire. Request will be
pended and reviewed by Qualis Health.
Yes
No
Thoracic Spine Imaging updated 02/09/2011
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