Thoracic Pain: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of thoracic spine and MRI of cervical spine. Based on the American College of Radiology (ACR) Appropriateness Criteria, it is usually appropriate to evaluate chronic neck pain with MRI as recommended in this patient’s case. The records indicate that the patient’s initial x-rays demonstrated degenerative changes. As recommended by the ACR guidelines, the next course of action is MRI to help delineate the degree of arthropathy at each level. In addition, MRI can aid in the diagnosis of foraminal narrowing, canal stenosis, and disc protrusion as potential pain generators accounting for the patient’s symptoms.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging of the cervical spine, thoracic spine, and lumbar spine. According to the medical records, the patient has chronic neck and back pain.American College of Radiology appropriateness criteria indicate that magnetic resonance imaging may be appropriate when red flag symptoms or new neurologic findings are present. The records do not document acute changes in the patient’s cervical or lumbar symptoms since recent magnetic resonance imaging studies of those regions.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Oxycontin and magnetic resonance imaging (MRI), spinal canal and contents, thoracic; without contrast for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Argoff and Silvershein note that for chronic non-cancer pain, short and long acting opioid has been found to be effective. “A review of published studies found no data to suggest that either short acting opioids or long acting opioids are generally more efficacious for treating any particular chronic non-cancer pain condition.” Noting as well that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MRI of the spine. Medical literautre has established Appropriateness Criteria for several clinical presentations. Medical literature has listed appropriate approaches to both low back pain and chronic neck pain. Medical literature has not presented criteria for chronic thoracic pain, the same considerations apply to the mid-back as apply to the neck and the lower back. The medical literature’s “Chronic Neck Pain” criteria for patients who are NOT in the clinical setting of trauma, pre-existing malignancy, or infection, most closely resembles the patient’s clinical presentation. This medical criteria recommends plain x-rays as a first line study, and specifically states that MRI of the cervical spine is generally not appropriate.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for thoracic pain was denied, the published record says the denial is worth fighting.