During insurance audits, providers sometimes write a letter detailing why they believe a service is medically necessary. However, payers often do not consider these letters in their assessment. Instead of a letter, we suggest you consider the following while documenting.
🔹 Documentation of Prior Conservative Therapy Attempts: Insurance auditors look for evidence that the patient has undergone and failed to respond adequately to conservative therapies before proceeding to interventional pain procedures. This documentation should include details of the conservative treatments attempted, such as physical therapy, medications, injections, chiropractic care, acupuncture, or other modalities.
🔹 Description of Conservative Therapy Modalities: The medical record should clearly document the specific conservative therapies provided, including the type of treatment, frequency, duration, and response to each modality. Auditors expect to see comprehensive notes detailing the rationale for selecting conservative therapies, the patient’s adherence to the treatment plan, and any observed changes in pain intensity or functional status.
🔹 Reasons for Conservative Therapy Failure: Clinicians are expected to document reasons why conservative therapies were deemed ineffective or insufficient in alleviating the patient’s pain and improving function. This may include inadequate pain relief, intolerable side effects, lack of improvement in functional status, or contraindications to continued conservative management.
🔹 Clinical Justification for Interventional Procedures: The medical record should provide a clear rationale for transitioning from conservative therapy to interventional pain procedures based on clinical assessment findings, diagnostic evaluations, and patient-specific factors.
Auditors will then assess whether the decision to pursue interventional procedures was medically necessary and supported by objective evidence of treatment failure.
