Magnetic Resonance Imaging Of The Brain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain. This patient’s initial clinical presentation was most consistent with migraine with no abnormal findings on examination or significant change in headache pattern described. Therefore, his initial presentation is consistent with Variant 4, which did not support an indication for initial computed tomography (CT) or MRI. However, the patient has repeated complaints of headache and multiple visits suggest Variant 7 presentation, chronic headache presenting with new features or increasing frequency. As a negative head CT scan is not the preferred imaging modality in the non-acute setting, this supports an indication for the requested MRI of the brain. The patient does describe worsening headache during the emergency department visit.

A 28-year-old female enrollee has requested for a magnetic resonance angiography (MRA) of the head, MRA of the neck and magnetic resonance imaging (MRI) of the brain for evaluation of her headache, seizure and facial paraesthesia. Findings: The physician reviewer found that MR imaging of the brain should be considered as the study of choice in evaluating patients with demyelinating disease since computed tomography (CT) scanning will not be able to show multiple sclerosis (MS) plaques with reliability, even after intravenous (IV) contrast administration. It is not, however, the choice for imaging an acute ischemic attacks, unless other techniques such as diffusion weight imaging are applied. Imaging of the intra/extracranial vasculature could be achieved with CT angiography and/or ultrasound.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methicillin-resistant staphylococcus aureus (MRSA) assessment, neurology assessment, magnetic resonance imaging (MRI) scan, Ross Information Processing Assessment, Second Edition (RIPA-2) testing, and daily physical therapy. Findings: The physician reviewer found that with regards to the request for MRSA assessment, active surveillance consists of performing screening cultures (of the nares, oropharynx, and/or perineum) to identify asymptomatic patients who are colonized with antibiotic-resistant bacteria. This is typically performed in a hospital with the goal of prevention of spread of MRSA to other patients. Active surveillance cultures appear to be most useful in the setting of hospital outbreaks and among patients at high risk for MRSA carriage.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain.Findings: The physician reviewer found that patient presents with a history of Morgellons disease with reported neurological symptoms. Morgellons disease is a dermatological condition characterized by the presence of multicolored microscopic fibers in skin lesions or lying under unbroken skin (Fesler, et al.). According to the best available scientific evidence, Morgellons disease is considered a dermopathy associated with tick-borne /disease. In addition to fiber production, some patients may experience stinging, biting, and crawling sensations. Systemic symptoms may include fatigue, joint pain, cognitive difficulties, and neuropathy (Middelveen, et al.).

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 Of The Brain, then check the rights and deadlines that apply to your plan.