Guideline Description

MedSolutions guideline philosophy: seek the best imaging procedure for each patient, at the most appropriate time in the diagnostic and treatment cycle. MedSolutions' guidelines are driven by patient symptoms, not be studies requested. They are designed to promote respectful, thoughtful discussion and negotiation with referring physicians, and initiate proactive information sharing.

Our carefully developed guidelines for CT, MRI, MRA, obstetrical ultrasound, bone mineral densitometry and cardiac nuclear medicine support the radiology utilization management process. These guidelines are not intended to supersede or replace sound medical judgment, but instead facilitate the identification of the most appropriate imaging procedure for each patient. They are designed to:

• Promote respectful, thoughtful discussion and negotiation with the patient’s referring physician

• Ensure consistent case review

• Augment our nurses’ clinical knowledge

• Initiate proactive information sharing

Built-in physician education. We believe that educating the referring physician to the proper sequence of imaging studies is a key component of our service delivery. When a decision is made for denial of an imaging request based upon the clinical guideline criteria, the criteria must be made available to the referring physician upon request.

Medical Foresight. Our guidelines, applied by our experienced, well-trained medical staff, go beyond just approving or denying a procedure. We first explore the patient's condition, and consider the entire diagnostic and treatment process. In seeking the most appropriate diagnostic tool first, we regularly eliminate potential redundancies that occur in the diagnostic process. 

Consultative. Our staff works with referring physicians to determine the most appropriate imaging for each individual patient. When requested procedures do not meet the clinical guidelines, our nurses suggest alternative imaging studies or treatment plans more beneficial to the patient. Our Medical Directors are always available for further clinical consultation.

Guideline Origin
The guidelines are a product of an extensive literature search and have incorporated expertise from the Royal College of Radiology in the United Kingdom, The University of Arizona Radiology faculty, The Kerr White Institute for Health Services Research at Emory University, The American College of Radiology, and the American College of Cardiology. The guidelines were developed in conjunction with a select group of objective clinical experts from a broad range of specialties.

Functionality
MedSolutions’ licensed nursing and physician staff applies the guidelines to ensure selected imaging procedures meet key criteria before they are performed, the most appropriate procedure is chosen, and the procedures are performed by qualified providers.

Guideline Review
In keeping with MedSolutions’ support of the individual health plan’s medical and strategic objectives, our medical team works with medical leaders in each community to establish acceptance of these guidelines and to make modifications reflective of community standards.  

Members of MedSolutions’ Guideline Review Committee review the clinical guidelines for the utilization management program at least annually. This committee and often a committee of the health plan meet to ensure continued compliance and relevance to the defined goals and/or objectives of the health plan and medical community serving the plan’s members. Appropriate revisions to the guidelines will results in a corresponding revision to the prospective and retrospective utilization review programs. In addition, MedSolutions’ physician peer reviewers and specialist physician panels will review the guidelines annually and make recommendations as appropriate.

It is MedSolutions’ belief that when a decision is made for denial of an imaging request based upon the clinical guideline criteria, the criteria must be made available to the referring physician, facility and member upon request.

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