Meet Don
Don* is a 60-year-old patient who’s been suffering from persistent lower back pain following a motor vehicle accident over a year ago.
*Not patient’s real name. Images are for illustration purposes only.
Diagnosing Don
Don’s primary care physician submits an authorization request for an MRI of the lumbar spine region.
IS IMAGING THE RIGHT NEXT STEP?
Based on Don’s symptoms, evidence-based guidelines recommend a six-week course of provider-directed non-surgical care that can include physical therapy (PT). If function is not restored and if symptoms do not improve through provider-directed non-surgical care, a lumbar spine MRI could be the next step within three months of the start of non-surgical care.
Since Don has not undergone any provider-directed non-surgical care, EviCore determines that an MRI is not in his best interest at this time. However, his story doesn’t end here—and neither does EviCore’s support.
Expert Clinical Review
EviCore MSK reviewers have the same specialty clinical expertise as requesting providers. They thoroughly and efficiently review each request to ensure procedures are in accordance with evidence-based medicine and national guidelines to promote the most clinically appropriate and cost-effective care for each patient.
Going Beyond Prior Authorization
EviCore's management of advanced imaging requests provides line of sight into musculoskeletal (MSK) related treatment. This connection allows EviCore’s MSK specialists to quickly identify and proactively outreach patients for our Spine corePath program—a concierge-level service that engages and educates patients about less invasive treatment options, and empowers them to take greater control of their care through shared decision-making with their provider.
Within 72 hours of the change in treatment plan, a Consumer Engagement advocate contacts Don to offer support.
Through a series of initial and follow-up discussions, Don is educated on effective strategies for managing his low back pain and the advantages of provider-directed non-surgical treatment, such as PT.
HOW DO WE HELP?
Empowering Patients to Take Control of Their Care and Costs
After completing physical therapy, Don reports an improvement in his pain, and feels confident in his ability to manage it moving forward. As a result, he sees no reason to pursue further testing.
WHAT IF HE’D GOTtEN AN MRI FIRST?
Patients with low back pain whose first service is advanced imaging instead of physician-directed
non-surgical treatment are nearly 4x more likely to have spine surgery and spend more than
double on health care costs.*
Don reported the program was helpful and was quoted as saying:
"It's so nice to know that someone is concerned with my well-being. This information has been so positive and motivating."
* Based on analysis of EviCore claims data.
Achieving Better Outcomes
EviCore by Evernorth’s holistic programs, like Spine corePath, go beyond medical necessity review and prior authorization. We support providers and their patients along the care journey to help ensure the safest, most effective, and most cost-effective tests and treatments for each patient’s needs.
The result: Better health outcomes, and lower costs for everyone.
Learn more at evicore.com