Magnetic Resonance Imaging denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging for treatment of the enrollee’s knee pain.Findings: The physician reviewer found that the American College of Radiology (ACR) has established appropriateness criteria for the evaluation of various clinical presentations. Under their category of chronic atraumatic knee pain, the first recommended study is a plain x-ray, which this patient has already had. In patients with demonstrated degenerative changes, in consideration for surgery, the ACR considers MRI appropriate. As stated by the ACR, “MRI is more sensitive than radiography and provides more specific information compared with radionuclide bone scan.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for open magnetic resonance imaging (MRI). A researcher explains, “Most women choose silicone gel-filled breast implants because of their natural feel; however, core clinical trial data show a high risk of rupture over ten years. Because cross-linking makes silicone gel somewhat cohesive, it tends to remain within the capsular scar if the shell ruptures, maintaining the volume of the breast. This is why patients are not aware that an implant has ruptured and why it is called a ‘silent rupture.’ The ruptured implant may remain in place for years until discovered at a subsequent implant procedure, such as a size change, or diagnosed during evaluation of signs or symptoms, such as capsular contracture, pain, a lump, change in shape, or abnormal mammogram. At this time, the U.S.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging to determine if there is sciatic nerve damage for evaluation of his history of lower back pain. Findings: The physician reviewer found that the medical literature supports obtaining an imaging study when it will change the course of therapy. The correlation between magnetic resonance findings and clinical symptoms requires strict clinical correlation. The American College of Radiology (ACR) has established appropriateness criteria to evaluate various clinical presentations, including low back pain. The guidelines indicate that imaging patients with acute low back pain (LBP), of less than six weeks duration and no red-flag symptoms provide no clinical benefit (ACR Appropriateness Criteria).

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRIs) for the following body parts: left knee, left hip, thoracic spine, lumbar spine, sacral, and pelvis. Regarding the patient’s thoracic, lumbar, and sacral pain, according to Radiology guidelines, if the pain persists after four-to-six weeks of conservative management, and the patient is a surgical or intervention candidate, then an MRI of the thoracic/lumbar spine is the usually the appropriate next examination. Radiographs are the initial imaging examination that are recommended. In this case, the patient has not undergone radiographs, so these MRIs are not indicated.

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 Magnetic Resonance Imaging, then check the rights and deadlines that apply to your plan.