Utilization Management Emergency Services Policy

The Medical Management Committee, a committee of the United Physicians Board of Directors, has determined, based on the activities delegated to UP by Health Alliance Plan and Blue Care Network for the review of nuclear cardiology studies, EGDs and MRIs of the lumbosacral spine, that these are elective in nature and will not fall under the "urgent" category.  Should a physician request an immediate MPI, our cardiologists not the patient should be sent to an Emergency Room or cardiac cath lab rather than have an MPI on an urgent basis.  Similarly, if an EGD is required "urgently,"  the patient should be treated for the condition (bleeding, obstructions, etc.) and no authorization is required.  Since our lumbosacral spine criteria requires 4-6 weeks of back pain prior to obtaining the MRI, it is highly unlikely that an "urgent" request is needed.  Even though our physician reviewers are available on a 24/7 basis, the Committee reiterates that "urgent" is defined by the clinical condition and not the lack of planning on the part of the physician or patient (i.e., scheduling difficulties of desire.

Harry Doerr, MD, MHSA
Chair, Medical Management Committee
Adopted 8/1/10
Reaffirmed 6/1/11
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