Determining the appropriateness of a medical procedure or treatment plan is one of the most difficult and delicate challenges a payer can face. Specialized Physician Review (SPR) helps payers make decisions related to complex medical conditions with written opinions by board-certified, actively practicing physicians.
Unmatched expertise in medical appropriateness opinion
SPR provides independent, expert opinion services to assess the appropriateness of a proposed treatment or procedure. We provide written opinions from a board-certified, actively practicing physician/surgeon. These reviews help your organization make the right decision, at the right time, regarding treatment for complex medical conditions. Written opinions include:
- A summary of the patient's clinical status
- The reviewer's expert opinion as to the appropriateness of the proposed procedure or treatment specific to a patient's current clinical condition
- A summary of relevant and supporting literature
- References to alternate therapies, when appropriate
- A comparison with community standard
Each comprehensive review is completed within 5 business days from receipt of a patient's relevant medical records.
Types of SPRs
Reviews are performed for complex medical conditions, including:
- A proposed transplant, ABO incompatible transplant or transplant for individuals with elevated panel-reactive antibody levels
- Solid organ or stem cell transplantation
- Retransplantation
- Cancer
- An unfamiliar treatment protocol for a complex medical condition
- Services proposed as a bridge to transplantation
- Application of new medical devices such as ventricular assist devices
- Congenital heart disease
- Surgical management versus transplant for congenital heart disease
