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Ontario Health Insurance Plan

OHIP Bulletins


INFOBulletin

Keeping Health Care Providers informed of payment, policy or program changes

To: Providers, Hospitals, Primary Care, and Nurse Practitioners

Published by: Health Services Branch, Ministry of Health and Long-Term Care

Date Issued: August 22, 2018

Bulletin Number: 4712

Re: Low Back Pain Imaging Studies (X-ray, Computer Tomography (CT), and/or Magnetic Resonance Imaging (MRI))

Posted Electronically Only

PDF Version Portable Document Format | 1 Mb | 


Important Reminder

Update to Bulletin # 4561, Bulletin #4563, and Bulletin #4569.

Low Back Pain Imaging Study Payment Requirements:

OHIP payment is only authorized for services that are medically necessary to the individual patient’s circumstances.
X-ray , CT, and MRI studies of the lumbar spine should not be routinely ordered or rendered for low back pain without suspected or known pathology. Examples of suspected or known pathology include but are not limited to infection, tumour, osteoporosis, ankylosing spondylitis, fracture, inflammatory process, radicular syndrome, and cauda equina syndrome.

These requirements for payment are supported by the evidence in numerous published studies, clinical practice guidelines and expert panel recommendations. It has been clearly demonstrated that the majority of diagnostic imaging tests of the lumbar spine demonstrate abnormalities that are typically non-specific in both symptomatic and asymptomatic individuals (e.g. the majority of these abnormalities is due to natural ‘wear and tear’). Furthermore, the evidence shows that X-ray, CT and MRI for chronic low back pain is not a useful test (i.e. does not change the management or outcome of the patient) unless there are specific symptoms or signs that suggest a serious cause for pain.

Record Keeping of the Ordering Provider and the Diagnostic Radiologist:

The ordering provider can demonstrate medical necessity of the imaging study by documenting in the clinical record the reason for the imaging study based on the clinical circumstances of the patient. The clinical reasons why the test is being ordered should also be identified on the requisition for the imaging study to inform the interpreting physician.
The outcome of the imaging study does not determine if the test was medically necessary. Medically unnecessary services are not insured and claims for uninsured services are not payable by OHIP.

Consequences of Unnecessary Imaging Studies:

Where there are concerns regarding the medical necessity of imaging studies completed, the Ministry of Health and Long-Term Care (‘ministry’) may contact the ordering provider and/or the diagnostic radiologist as part of the physician payment review process.  The ordering physician may be responsible to reimburse OHIP for payments made for diagnostic services that are found to be not medically necessary in accordance with s. 18.2 of the HIA.

Additional Information on Ministry Supports for Low back Pain

The ministry has expanded supports for patients with musculoskeletal (MSK) conditions including low back pain that will further improve appropriate access to diagnostic imaging studies.

The Existing Inter-professional Spine Assessment and Education Clinics (ISAEC):

ISAEC locations in Toronto, Hamilton, and Thunder Bay provide an inter-professional model of care for people that have persistent low back pain and/or related symptoms (e.g., sciatica, claudication). Patients referred to ISAEC receive shared care between primary care providers (PCPs), advanced practice providers (APPs), and chronic pain prevention and self-management specialists, with expedited access to imaging and additional specialist consults if necessary. The result is 95% reduction in surgical consults and diagnostic imaging orders, 98% patient satisfaction and substantial increase in provider satisfaction.

The Introduction of New Rapid Access Clinics (RACs) for Musculoskeletal (MSK) Conditions:

Building on successful evidence-based models like ISAEC, the ministry is supporting the expansion of MSK RACs across the province to all Local Health Integration Networks (LHINs). RACs will follow the ISAEC model of care, and will provide services for patients with hip/knee osteoarthritis and low back pain. Patients referred to their local RAC for assessment will have access to imaging studies when appropriate and surgery when necessary, or they will be given a self-management plan with non-surgical measures and may be connected with local community supports. With RACs in place, primary care providers should defer diagnostic imaging for their low back pain patients without suspected or known pathology prior to being referred. Look for further information to be provided through your LHIN.

Available Resources for Physicians:

TheCentre for Effective Practice has developed a Low Back Pain Toolkit to assist with the assessment and management of patients with low back pain in primary care settings. This toolkit helps to reduce the number of unnecessary diagnostic tests, improve wait times, and enhance patient care.

The Joint Department of Medical Imaging at the University Health Network has partnered with family physicians, specialists, radiologists, and system leaders from across the province to develop evidence-based imaging pathways for four common clinical scenarios: (1) Low back pain, (2) Knee pain, (3) Headache, and (4) Symptoms suggestive of TIA/stroke. All imaging pathways are available online via the Diagnostic Imaging Appropriateness Tool (DI-App).

This INFOBulletin is a general summary provided for information purposes only. Physicians, hospitals, and other health care providers are directed to review the Health Insurance Act, Regulation 552, and the Schedules under that regulation, for the complete text of the provisions. You can access this information at. In the event of a conflict or inconsistency between this bulletin and the applicable legislation and/or regulations, the legislation and/or regulations prevail.

For More Information

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