Spine Imaging: 5 Strategies for Meeting 'Milliman Criteria' Requirements

Written by By Douglas Smith, MD, Founder of Musculoskeletal Imaging Consultants | April 12, 2013 | Print  |
The Milliman accounting firm has proposed a series of clinical and imaging criteria to satisfy and document as best practice before a surgical procedure is performed. Many insurance companies have adopted the Milliman criteria as absolute requirements before approving surgical fusions and other procedures and will reject pre-authorization unless each of the Milliman criteria are specifically documented in the medical records submitted in the pre-authorization packet. Ideally, the entire pre-operative evaluation process would be designed to document the Milliman criteria. Technology and terminology best practices must be adopted and all members of the preoperative planning team must be sensitive to the importance of documenting how the Milliman criteria are satisfied in each patient's medical record. Here are some components of Milliman sensitive pre-operative evaluation process.Use weight-bearing imaging techniques to demonstrate maximal compression of neural structures and spinal instability.

Patients experience more pain and radiculopathy when weight-bearing than when lying down. A UCLA study demonstrated 30 percent more nerve compressions than MRI examinations obtained in recumbent position. European experience with the Esaote C-scan Brio (weight-bearing MRI) during the past five years reports similar increased sensitivity. Increased size of disc herniation, buckling of ligamentum flavum, increased listhesis, and increased neural compression have all been documented using weight-bearing MRI images compared to the recumbent images performed at the same sitting. Weight bearing MRI should improve the chances of successful surgical pre-authorization by 20 to 30 percent.

Utilizing technology and techniques optimized for documenting spinal instability.

Biomechanical instability is complex, dynamic process with three-dimensional components that is difficult to fully characterize in any single measurement. Experienced spine surgeons apply a Gestault overview appraisal that comes with experience.

a.    Decubitus positioning is more sensitive than upright flexion extension views for documenting spinal instability.

Unfortunately the "Milliman criteria" apply only translational displacement of the vertebral bodies on plain radiographs obtained in the standing position in flexion/extension and lateral bending. One look at a standing patient with back spasm would demonstrate the inherent flaw in this process. The spasm is designed to apply muscular control to limit excessive motion or neural compression but it also restricts the amount of measurable intervertebral translation. Muscle spasm decreased when the anti-gravity muscles are relaxed when the imaging is obtained in lateral decubitus position. Coach your radiographer to allow the patient to relax in lateral decubitus position and allow muscle spasm to ease before slowly curling into a ball (flexing) and then extending. If the patient is rushed, the muscles spasm and one will not see the true spinal translation. Remember a technologist rushing a patient with muscle spasm may mean that their surgery will be denied if their muscle spasm hides their instability. Just like surgery — it all about technique!

b.    Computerized analysis of controlled spinal motion during lateral bending and flexion-extension.

Linear and angular measurements of curved vertebral bodies have inherent inter-observer and intra-observer error. Three-dimensional scoliosis must be accounted for by the radiologist during measurement. Ortho Kinematics has a developed novel solution using patent pending computer analysis of fluoroscopic images of the spine in both controlled motion flexion/extension and lateral bending to more accurately and reliably document the complex motion of the unstable spine. We are currently comparing these results to conventional flexion/extension radiographs.  I believe that this objective measurement technique of controlled spinal motion will become the new gold standard for documenting spinal instability.

c.    Milliman criteria sensitive radiology reports from dedicated spinal radiologists

The radiology findings section must specifically document the magnitude of translational and rotational motion and specifically state whether it meets the Milliman instability criteria. MRI and CT reports should specifically document the magnitude of any compression of the spinal cord or nerve roots, spinal canal dimensions and the severity of any neural compression. Attaching the key images demonstrating measurements made by the radiologists (RadPics®) using digital calipers directly to the report will greatly improve your surgical pre-authorization success rate.

d.    Close working relationship between the Surgeon, Patient and Radiologist.

It is imperative that the radiologist responsible for documenting the imaging section of the Milliman criteria be aware of all of the components of the patient’s history and clinical features so that the report generated will accurately address all of the requisite Milliman criteria required for successful surgical pre-authorization for your patient. If you are looking for instability in an exam, let your radiologist know. In many cases, the detail and clinical usefulness of the study is directly proportional to the quality of the history and knowledge of the working diagnosis and surgical plan.

e.     Systematic approach to demonstrating and documenting instability

Create a checklist or program to make sure you have all the documentation necessary from the beginning. State of the art technology, attention to detail, a systematic approach and optimized radiology reporting by dedicated spine imagers will greatly improve your surgical pre-authorization rate.

At Spinal Motion Assessment Laboratory of San Antonio, we incorporate all of these cutting edge modalities into our spinal instability assessment process using weight-bearing MRI by Esaote C-scan Brio, computerized assessment of controlled motion fluoroscopic examination by Ortho Kinematics, and generate a "Milliman Criteria" sensitive, clinically oriented, radiology report containing annotated key images (RadPics®) by dedicated spine imagers.

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