Tom's Take Blog

January 21, 2015

How has medical necessity and extra testing escalated into such a big issue?

What’s happening today is that patients are receiving extra procedures, tests and treatments that don’t qualify as medically necessary. This is a growing issue in so many areas, but especially with scans and electrodiagnostic (EDX) testing. As these procedures are ordered, patients often feel they must follow doctor’s orders.


Consider this: We reviewed a claim that billed for EDX testing, and based on the results, the patient was set to be scheduled for bilateral carpal tunnel surgery. After we flagged and sent the file for a peer independent review, it was found that the EDX testing wasn’t even necessary since more traditional methods like wrist splints and physical therapy weren’t tried first and there were no definitive signs that the patient even had carpal tunnel syndrome (CTS). On top of that, those pricey EDX tests also proved inconclusive that the patient had CTS. Because of this intervention, the patient cancelled the surgery – one that would have cost up to $15,000!


My advice to you is to always consider the big picture. Is this type of testing really necessary based on your symptoms? How long have your symptoms been present? Have more conservative methods been tried without success? Are there any potential coverage issues with your plan?


At Cypress, we see many cases where patients are urged to undergo advanced tests and treatments before even the most basic measures are taken. We’ve also seen the hefty price tag attached to these procedures and how quickly the costs can spiral out of control.

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