I just got off the phone with an insurance company’s medical reviewer. We were discussing why one of my patients needed an MRI following her auto accident. The conversation started normally enough – he asked about her symptoms, her response to initial treatment, and what we were seeing clinically.
Then he asked a question that is normally completely legitimate, but he was asking it in a way that revealed a fundamental misunderstanding about how healthcare should work:
“How would the MRI results change your treatment plan?”
He was asking specifically about my chiropractic adjustments, and only that. An explanation of how the treatment plan would be changed based on the outcome of the MRI was already included in my notes . He didn’t seem to care about that. That’s when I understood the true motive – to deny using any information possible.
How a test would change a treatment plan is actually a fair question. A diagnostic test should change things. If nothing would change regardless of the results, then why do the test? The reviewer was doing his job by asking for medical necessity.
But he was focused on the wrong person.
It’s Not About Me
It’s not about me or what I’m doing inside the office. It’s not about justifying my treatment approach or fine-tuning my chiropractic techniques.
It’s about the patient and what she needs.
In fact, the MRI might reveal that this patient doesn’t belong in my office at all – at least not as her primary spine care provider.
My goal for any patient – especially after an auto accident – is to create an accurate diagnosis, prognosis, and treatment plan. Everything flows from accurate diagnosis. Without it, we’re making critical decisions without complete information.
What Accurate Diagnosis Actually Means
When someone is injured in a car accident, there are multiple possible outcomes:
- They may respond well to conservative chiropractic care and that’s all they need
- They may need referral to pain management for intervention in addition to chiropractic
- They may require surgical consultation with continued supportive care
- They may need a combination of these approaches
But here’s the critical point: I can’t determine the best path forward without knowing exactly what we’re dealing with.
An MRI might show a disc herniation that requires epidural injections. It might reveal nerve compression that needs surgical evaluation. It might document soft tissue injuries that explain why someone isn’t responding to conservative care as expected.
Sometimes the MRI confirms that continued chiropractic care is the appropriate path. Sometimes it shows we need to add pain management. Sometimes it indicates surgery is necessary.
The point is: we need to know. The patient deserves to know.
The Real Issue
The reviewer’s question was only focused on a way to justify denial of the MRI.
Diagnostic imaging isn’t about me justifying what I’m already doing. It’s about confirming whether what I’m doing is what the patient actually needs – or whether they need something different, something additional, or something I cannot provide at all.
This shift in perspective matters because it determines whether we’re treating the patient or protecting a treatment plan.
The Insurance Company Perspective
Insurance companies understand the importance of accurate diagnosis. That’s precisely why they fight so hard against it.
Every diagnostic study approved is a potential pathway to more treatment. Every accurate diagnosis is a claim they’ll likely have to pay. So they create barriers – require peer reviews, demand justifications, question medical necessity.
But the honest answer is: the MRI might tell me she needs care I cannot provide.
And despite that explanation, he denied the MRI study.
What Patients Should Know
The patient will still get her imaging – I’ll make sure of that. The fight with the insurance carrier will continue. But this interaction highlights something patients need to understand.
If your doctor is recommending diagnostic imaging after an accident, it’s not about padding bills or justifying their services. It’s about establishing what’s actually wrong so they can determine what you actually need.
Sometimes that means continuing with the care you’re already receiving. Sometimes it means referring you elsewhere. Sometimes it means collaborative treatment with multiple providers.
But it always starts with accurate diagnosis.
When an insurance company asks “how will this change your treatment,” they’re hoping for an answer that keeps you within the current scope of care. They’re not asking “what does this patient need” – they’re asking “can we avoid additional claims?”
The Reality of Auto Accident Injuries
Auto accident injuries are complex. Two patients with similar mechanisms of injury can have vastly different tissue damage. Symptoms don’t always correlate with severity. What appears to be simple muscle strain can mask more significant underlying pathology.
This is why imaging matters. This is why accurate diagnosis comes first and we’ll base decisions on treatment on her needs, not on what’s most convenient for an insurance company’s bottom line.
That’s how healthcare should work.
