Definition of "Medical Necessity"

• http://en.wikipedia.org/wiki/Medical_necessity
• CPT Definition: Physicians’ Current Procedural Terminology (CPT®), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties.
• ICD-9 Definition: The ICD9 coding system is an international classification system which groups related disease entities and procedures for the purpose of reporting statistical information. Like the CPT the purpose of the ICD9 is to provide a uniform language and thereby serve as an effective means for reliable nationwide communication among physicians, patients, and third parties.
• National Coverage Determination (NCD)
• Local Coverage Determination (LCD)
• ADT?

http://www.radmd.com/misc_pages/select_guidelines.htm: 
Guidelines by Health Plan, Modality, and Exam Type.

Tools for Checking Medical Necessity:

• 3m
• ACR Coding Source:
• AdvancedMD:  Medical Office Software.  Scheduling, Eligibility, Charge Chapture, Billing
• AHRA.com:
• CodeCorrect.com:  Annual License for $400
• CodeMap Medical Necessity Report
• CodeMap® Medicare Medical Necessity Guide for Radiology Procedures:  $700
• HalfPenny.com: MPChecker is a medical necessity checking software tool that enables healthcare organizations to quickly and efficiently verify medical necessity for multiple departments, including lab, radiology and surgery. Web-based solution or a stand-alone system.
• HealthHelp:HealthHelp’s nine evidence-based radiology benefit management programs address factors that inflate the cost of diagnostic imaging and radiation oncology—from procedure ordering to patient education.
  • RadCert™: Collaborative Preauthorization
    • RadCert™ builds physician knowledge through traditional precertification.
  • RadDirect™: Radiology Scheduling
    • RadDirect schedules services with inexpensive, accessible, and convenient in-network providers.
  • RadAlert™: Referral Pattern Analysis and Modification
    • RadAlert allows payers to monitor ordering patterns and identify providers who may need ordering behavior modification training.
• MedAssets:  This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; 866-323-6332
• Medlearn.com:  Books on Radiology Coding
• PassportHealth.com:
  • The Passport family of companies delivers administrative, clinical and financial tools to help health care providers get paid accurately and faster. Its health care information technology and services are used by approximately one-third of all U.S. hospitals and more than 5,000 other health care providers
• Medical Necessity Validation
• PremSoft.com:  No tools
• RBMA.org
• The Radiology Manager's Handbook:  $200

Breast Medical Necessity:

• http://www.westcoastradiology.net/webdocuments/BREASTMRIINDICATIONCHART.pdf

CardioVascular Medical Necessity:

• http://bhavin.typepad.com/cardiac_images/indications/

Medicare Guidelines for Medical Necessity:

• Medicare Coverage Center
• RadiologyInfo:  Simpler Listing of Indications for various studies.  Doesn't have ICD-9 Codes

PET Medical Necessity:
http://www.nepetimaging.com/clinical.html

Medical Necessity Links:

• http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a053805.htm
• http://www.anthem.com/medicalguidelines/va/f3/s10/t1/pw_ad081095.pdf
• http://www.aafp.org/afp/20000115/411.html
• http://cchs-dl.slis.ua.edu/clinical/orthopedics/lower/knee-fracture.htm
• http://www1.wfubmc.edu/pet/Med_Professionals/Indications.htm
• http://www.nepetimaging.com/clinical.html
• http://www.aetna.com/cpb/medical/data/1_99/0071.html
• http://www.ohca.state.ok.us/provider/updates/pdflib/MRG_mri_Extremities0805.pdf
• https://www.codemap.com/content.cfm?id=5440&contractorid=195
• http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9599&nbr=5120
• http://www.springerlink.com/content/44610r733th325t1/
• http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a053812.htm
• http://www.healthlink.com/provider/medpolicy/policies/guidelines/RAD/CT_MRI_hips.html I think you already have this one
• http://www.medicalnewstoday.com/articles/49089.php
• http://www.nepetimaging.com/medicare.html
• http://www.dcamedical.com/referring-physicians-imaging-centers-mri-ct-delray-boynton-florida.htm#appropriateness
• http://www.medicalnewstoday.com/articles/74407.php
• http://www.guideline.gov/summary/summary.aspx?doc_id=10601&nbr=005543&string=cardiac+AND+calcification
• http://content.onlinejacc.org/cgi/content/full/46/8/1587?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Appropriateness+Criteria&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
• https://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/MNC.asp
• http://mt1-bcbs.bcbsmt.com/bsd/MedicalPolicy.nsf/7f2b01247cec058a87256cb50076b393/0be51be830b3e656872572f00061247b?OpenDocument

MRI Medical Necessity:

• NIH Guidelines for MRI Indications
• Blue Cross Blue Shield of Florida - Appropriate MRI Indications - Click on the radiology link and study type on the left
• MRI Clinical Indications by Government of Ireland
• http://mcgs.bcbsfl.com/?doc=Magnetic%20Resonance%20Imaging%20(MRI)%20Orbit,%20Face,%20TMJ,%20and%20Neck
• http://mcgs.bcbsfl.com?doc=Magnetic%20Resonance%20Imaging%20(MRI)%20Upper%20Extremity