Statements of Medical Necessity

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Statements of Medical Necessity

Post by Admin on Thu Oct 08, 2015 11:46 am

MEDICAL NECESSITY OF TREATMENT-CROFT STANDARDS.

The supporting chart notes should always contain a statement of medical necessity using either the Croft Guidelines of the MCA Standards of Practice.

The Croft Guidelines have 2 categories of injury;


  • Grade III-Moderate Injury (limitation of range of motion, some ligamentous injury, neurological findings present):

    Grade IV-Moderate to Severe Injury (limitation of range of motion, ligamentous instability, neurological findings, disc derangement):

MEDICAL NECESSITY-GRADE III

Grade III-Moderate Injury (limitation of range of motion, some ligamentous injury, neurological findings present):

“Medical necessity: This treatment plan is consistent with the Croft Guidelines which have been endorsed in “Best Practices & Practice Guidelines” #NGC-7125, U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality.  This is a Grade III (Moderate) injury which requires daily treatment for 2 weeks, treatment 3 times/week for 10 weeks, 2 times/week for 10 weeks, 1 time/week for another 10 weeks, 1 time a month for six months.”

MEDICAL NECESSITY- GRADE IV

Grade IV-Moderate to Severe Injury (limitation of range of motion, ligamentous instability, neurological findings, disc derangement):

“Medical Necessity:  This treatment plan is consistent with the Croft Guidelines which have been endorsed in “Best Practices & Practice Guidelines” #NGC-7125, U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality.  This is a Grade IV (Moderate to Severe) injury which requires daily treatment for 3 weeks, treatment 3 times/week for 16 weeks, 2 times/week for 12 weeks, 1 time/week for another 20 weeks and PRN care thereafter.”

MEDICAL NECESSITY FOR MRI.

The medical necessity for the MRI scans that have been ordered is established by the Standards of the American College of Radiology and the Agency for Healthcare Research & Quality (AHRQ) because of the presence of the following clinical signs (pick the right ones):


  • Radiculopathy and/or paresthesia
    Neurological deficit
    The severity of the injury to the ligaments and enter spinal soft tissues following trauma
    Potential muscle, tendon, ligament tears;
    Spinal instability
    Ligamentous laxity
    Failure to respond to conservative care

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