Lumbar Spine MRI denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spine magnetic resonance imaging (MRI) without dye.According to the American Pain Society, surgical referral for chronic low back pain should be reserved for patients with disabling low back pain impacting the quality of life for greater than one year. However, there is mixed evidence for some of the most widely used interventional pain procedures, such as epidural steroid injections, facet injections, and radiofrequency ablation of the medial branch. Surgical procedures include spinal fusion or lumbar disc replacement. Additionally, lumbar degenerative disc disease without disc herniation, also known as discogenic pain, can be diagnosed as the pain source in the presence of a high intensity zone on the MRI.

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the lumbar spine. Findings: The physician reviewer found that in patients with lower back and leg pain, lumbar foraminal stenosis is an important consideration, especially in the presence of radicular symptoms, such as this patient’s shooting leg pain and weakness. Foraminal stenosis can develop as a result of progressing degenerative disc disease and can cause low back and leg pain with extension of the lumbar spine. Oftentimes, there is a lack of critical clinical findings in these cases and imaging is needed. In patients with chronic low back and persistent leg pain, imaging to evaluate for lumbar spinal stenosis is the standard of care. Radiological diagnosis is performed using multiple radiological modalities, particularly the lumbar MRI.

Where the denial was upheld

The patient has a history of lumbar radiculopathy. In a progress report, the patient reported pain over the upper back (right side greater than left), low back (equally affected on both sides) and the tail bone. The pain was described as sharp, with spasms and throbbing. The pain developed suddenly, and the symptoms had worsened over time. The pain had been present for greater than one year. The pain was rated as eight out of 10 and was moderately affecting the patient’s function. The pain/symptoms were made better with rest and the pain increased with bending forward, arching the back, and repetitive computer work. The physical exam revealed a straight leg raising test was equivocal bilaterally. Five out of five strength was noted in the bilateral lower extremities. Sensation was intact to light touch throughout bilateral lower extremities. Gait was normal.

Nature of Statutory Criteria/Case Summary: An enrollee has requested thoracic spine Magnetic Resonance Imaging (MRI) and lumbar spine Magnetic Resonance Imaging (MRI). The decision to obtain specialized cross-sectional imaging of the spine can be difficult. Pain is a very common complaint, and not all patients who have pain require Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). As a fundamental principle, any imaging study is only worthwhile if it will affect the management of the patient. In general, while plain x-rays are often performed for back pain, plain x-rays are often of little value. Apart from excluding significant anatomic abnormalities such as a scoliosis, anatomic variations, or destructive lesion, plain x-rays are generally non-contributory.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Lumbar Spine MRIwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.