Rotator Cuff Tears: Take Surgeons’ Word That MRI Is Needed

SAN FRANCISCO — Insurance companies’ policies to refuse authorization of MRI scans to diagnose rotator cuff tears until patients have first tried physical therapy have probably raised overall healthcare costs as well as burdened patients unnecessarily, a single-center study indicated.

Among 365 patients who had MRI scans after their initial visit with an orthopedic surgeon, 43% were found to have full-thickness tears and another 25% had partial tears, according to Caroline Gutowski, BS, of Rowan University’s Cooper Medical School in Camden, New Jersey.

MRI’s diagnostic yield was essentially the same whether or not patients had already tried conservative treatment such as physical therapy or steroid injections, she told attendees here at the American Academy of Orthopaedic Surgeons’ annual meeting. Among those with previous conservative treatment, 68% turned out to have a full or partial tear, as compared with 67% of those with no prior therapy.

Gutowski noted that a standard 6-week course of twice-weekly physical therapy within the Cooper system costs $2,328 while an MRI costs $2,268. Thus, costs were effectively doubled for the two-thirds of patients who first tried conservative treatment but still needed imaging to understand their condition.

The results provided “validation for a specialist’s clinical suspicion for [rotator cuff] tear” at an initial examination, she said. “Decision of physical therapy versus timely imaging may be better left to a specialized clinicians rather than insurance companies.”

Insurers’ policies around advanced imaging didn’t come from nothing. Many studies have indicated that such imaging is overused for conditions such as low back pain. But demands for step-based approaches and prior authorization have become more inflexible, giving rise to another form of clinical suspicion: clinicians’ belief that insurers are less concerned about their customers’ health than with cutting costs.

Gutowski pointed out that when MRI scans are genuinely warranted, prior authorizations “delay intervention, prolong patient discomfort, and increase healthcare costs.”

For the study, she and colleagues reviewed records of 365 Cooper patients receiving MRI scans to evaluate suspected rotator cuff tears. Just under half of this group had previously received steroid injections or physical therapy. Mean age was about 60, a bit younger for those found to have no tear and a bit higher for those with full-thickness tears.

Not every patient with a complete tear went on to surgery — about 44% did not. Gutowski did not report on how these patients were ultimately treated or whether they were as satisfied with the outcome as those who did have surgical repair. Demographics and insurance status, however, were similar between those who had surgery and those who didn’t.

Limitations to the study included its single-center design and lack of detail on the specific physical therapies that some patients received. The latter meant that the researchers couldn’t determine the prevalence of rotator cuff tears among patients who underwent the full 6-week course typically required by insurers.

“Future studies are needed to delineate post-operative outcomes between patients who received preauthorization for MRI versus those who received mandated 6 weeks of physical therapy,” Gutowski said.