How I review a case for medical necessity.

Over the past several years I have reviewed medical charts for both insurance companies and pain clinics to determine if what has been recorded makes good medical sense and shows an appropriate level of care. What I offer in this work grows directly out of a long career in anesthesia and pain management. I have worked in both the operating room and the pain clinic for decades. Over the years, I have been involved not only in direct patient care, but also in teaching, program development, and the evaluation of how care is actually delivered. I have spent much of my professional life thinking about the ways in which decisions are made in real time often under pressure and with incomplete information. That experience shapes how I approach this work. I try to bring a practical and clinically grounded perspective that reflects how medicine is actually practiced not just how it is described in textbooks or guidelines.

In working with both insurance companies and pain practices I see my role as helping to bring clarity and balance to what is inherently a somewhat adversarial relationship. Insurance companies want to be sure they are not paying for unnecessary or excessive care. Pain practices want to be sure they are appropriately compensated for work that is often complex and time consuming. Both perspectives are entirely reasonable. My goal is to provide an honest and thoughtful assessment that both sides can rely on. In the end, appropriate documentation of good patient care needs to remain at the center of the discussion.

When I review a case I begin with the fundamentals. The first question I ask is whether the diagnosis actually fits the patient’s presentation. It is not uncommon to see imaging findings used as justification for intervention even when those findings are incidental or only loosely related to the patient’s symptoms. Degenerative changes for example, are nearly universal with age yet they are sometimes treated as if they are definitive pain generators. I look for a coherent clinical picture in which the history, the physical examination, and the imaging all point in the same direction. I also consider whether appropriate diagnostic steps were taken before moving to therapeutic procedures. In the case of spine interventions, that often means asking whether diagnostic blocks were used thoughtfully and interpreted carefully rather than simply proceeding directly to more definitive or more lucrative treatments.

From there, I look at how procedures are being used over time. It is one thing to perform an injection or an ablation when there is a reasonable expectation of benefit. It is another to see those same interventions repeated at regular intervals without clear evidence that they are helping. Patterns matter. When procedures are done frequently, with short intervals between them or in automatic series that do not appear to be guided by patient response, that raises concern. The cumulative exposure to steroids is also not trivial particularly in older patients or those with other medical problems. I consider not only whether each individual procedure can be justified in isolation but whether the overall pattern reflects thoughtful clinical judgment.

Closely tied to this is the question of outcomes. Pain scores alone are not enough. They are subjective and variable and often influenced by factors that have little to do with the intervention itself. What matters more is whether the patient’s function has improved in a meaningful way. Is the patient walking more comfortably, sleeping better, returning to activities that matter to them, or reducing their reliance on medications? When procedures are repeated despite little or no documented functional improvement, the rationale becomes increasingly difficult to support. Good care should have a sense of direction. It should move the patient forward even if slowly rather than cycling through the same interventions without meaningful change.

Patient safety is another factor I pay close attention to even though it is sometimes underemphasized in utilization discussions. Every procedure carries some degree of risk, even those that are considered routine. Repeated interventions increase cumulative risks. These include infection, bleeding, nerve damage, and others. The use of sedation or anesthesia deserves particular scrutiny. Many of these procedures can be performed safely with minimal or no sedation, yet deeper levels are sometimes used in ways that add both cost and risk without clear benefit. Looking at how sedation is used often provides a window into broader practice patterns.

Medication management also provides insight into the overall approach to care. The presence of ongoing opioid therapy, especially when there is little evidence of functional improvement, raises important questions. I look at whether medications are being used thoughtfully with appropriate monitoring and risk assessment or whether they are simply continued by momentum. At the same time, I consider whether non-opioid therapies have been adequately explored and optimized. A balanced approach to pain management should not rely too heavily on any single modality whether procedural or pharmacologic.

Diagnostic testing and monitoring can also become an area of excess. Urine drug screening has a clear role in certain settings particularly when opioids are prescribed, but very frequent testing without a clear clinical rationale, suggests that other factors may be influencing decision making. The same can be said for imaging studies that are repeated without a meaningful change in clinical status. These patterns are apparent when viewed over time rather than in isolation, and they can be quite revealing.

Documentation is where many of these issues either stand up or fall apart. The medical record should tell a clear and coherent story. It should explain why a procedure was performed, what the expected benefit was, and how the patient responded. When documentation is sparse, inconsistent, or heavily templated, it becomes difficult to justify the care provided. Time based billing is another area where the record must align with reality. Claims of prolonged visits or complex decision making should be supported by what is actually documented, not simply by what is coded.

Billing practices themselves deserve careful scrutiny but they are best understood in the context of the clinical picture. Unbundling of services, consistently high-level evaluation and management codes, and heavy use of ancillary services can all be appropriate in the right setting. The question is whether they are appropriate in the specific case. The site of service is also relevant. Procedures performed in an ambulatory surgery center may be entirely reasonable for some patients but not for others who could be managed safely in an office setting. When higher cost settings are used routinely without clear justification, it raises the possibility that financial considerations are influencing clinical decisions.

That leads naturally to the broader issue of incentives and potential conflicts of interest. Ownership in surgery centers, imaging facilities, or laboratories is not inherently problematic, but it does create a situation where utilization patterns deserve closer attention. When higher volumes of procedures, tests, or facility-based care align with financial interests, I look carefully at whether those services were truly necessary. Often these patterns become clear only when stepping back and looking across multiple cases rather than focusing on a single patient’s encounters.

I also find it useful to consider how a provider’s practice compares to that of peers. Most physicians develop patterns that fall within a certain range. When a provider consistently performs more procedures, orders more tests, or bills at higher levels than their peers, it does not automatically mean that the care is inappropriate, but it does warrant closer examination. Outlier behavior, especially when it is persistent, can be a meaningful signal, and can help put an individual case into a broader context.

Finally, I look at continuity and coordination of care. Pain management should not exist in isolation. Ideally there is communication with primary care physicians, surgeons, and other specialists. When care appears fragmented with multiple providers performing similar interventions without clear coordination, the risk of redundancy and patient harm increases. A well-managed case should reflect a longitudinal approach with a sense that someone is following the patient over time and adjusting the overall plan of care as needed.

Taken together these elements provide a comprehensive system to evaluate what is happening within a pain practice. My goal in doing this work is not to second guess individual decisions with the benefit of hindsight. Medicine does not lend itself to that kind of certainty. I am very aware of how difficult various decisions can be in real time. Rather, I look for patterns that reflect thoughtful patient centered care and distinguish them from patterns that suggest overuse, inefficiency, or excessive financial influences. I aim to provide an assessment that is fair, clinically grounded, and understandable to both medical and non-medical audiences. In my experience, that kind of balanced and practical perspective is what tends to be most useful to the people and organizations who seek out the kind of medical review I perform.