Cervical Spine MRI denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for brain magnetic resonance imaging (MRI) with and without contrast and/or cervical spine MRI. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of cervical neck pain or radiculopathy, in the setting of new or increasing non-traumatic cervical radiculopathy without red flags, an MRI of the cervical spine without contrast is considered usually appropriate. MRI is the preferred imaging study to evaluate the cervical spine in the setting of suspected nerve root impingement. According to the ACR appropriateness criteria for the evaluation of headache, in the setting of headaches without red flag symptoms, imaging is not appropriate. The patient actually attributes the headaches to his neck issues, per clinical notes.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a cervical spine magnetic resonance imaging (MRI) and/or thoracic spine MRI. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic cervical or neck pain, in the setting of chronic cervical pain without radiculopathy, in the absence of red flags or trauma, an MRI of the cervical spine may be appropriate following radiographs. If the pain does not resolve despite conservative management, then an MRI may be indicated to evaluate for disc or neurologic abnormality. In this case, the patient has tried and failed conservative management. Therefore, an MRI is the next appropriate imaging examination, as the results may impact the patient’s management.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for a cervical spine magnetic resonance imaging (MRI). The enrollee has cervical degenerative disc disease (DDD), upper back pain, pain in the left shoulder, and cervical spinal stenosis. He has a history of radiofrequency ablation on multiple levels. A magnetic resonance imaging (MRI) scan several years ago showed evidence of spinal stenosis, questionable myelopathy of the cervical spine at the C3/C4 and the C6/C7 level; and degenerative disc disease (DDD) at the C5/C6 level. A visit note indicates the enrollee was seen for chronic neck and base of skull pain. He also has left shoulder pain. On examination, strength was 5/5 to the upper and lower extremities. There were no sensory deficits to light touch, pinprick or vibration. Deep tendon reflexes were 2+.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical spine MRI and lumbar spine MRI.Findings: According to the American College of Radiology (ACR) appropriateness criteria for cervical neck pain, increasing nontraumatic neck pain without red flags would indicate radiographs as an initial imaging study. If the pain does not resolve despite conservative management after six weeks, then MRI may be indicated to evaluate for disc or neurologic abnormality. Conservative management includes physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs). In this case, the patient has bilateral numbness extensively evaluated and due to ulnar entrapment. The patient does not have a history of cancer or prior spine surgery, and infection is not suspected.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Cervical Spine MRI, then check the rights and deadlines that apply to your plan.