Magnetic Resonance Imaging Of The Cervical Spine 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 cervical spine (CPT 72141) and/or MRI of the lumbar spine (CPT 72148). With regard to the requested lumbar spine MRI, Srinivas and colleagues reported on a systematic review of the literature and “found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging versus usual care.” Furthermore, the authors noted that, “high-quality consistent evidence shows that imaging patients with acute low back pain of less than six weeks’ duration and no red flag symptoms results in no clinical benefit but is associated with harms.” Wang and colleagues stated that, “most acute episodes of low back pain are self-limiting, and imaging has limited utility because most patients with low back pain have nonspecifi…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. Conventional radiographs are the first step in the evaluation of neck pain, particularly to diagnose post-surgical complications, degenerative disease, spinal stenosis, or malalignment. After radiographs are obtained, a subset of patients may benefit from further imaging utilizing MRI. According to the American College of Radiology appropriateness criteria for the evaluation of cervical neck pain or cervical radiculopathy, in a patient with chronic cervical pain with degenerative changes seen on radiographs, MRI of the cervical spine is usually appropriate as the next imaging study.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. The records document that this patient presents with persistent right shoulder pain and migraine and a history of right shoulder surgery. However, there is a lack of documentation of any neurological deficits which would indicate a cervical spine etiology. Furthermore, no red flag symptoms are reported by the provider. In the absence of specific signs or symptoms of cervical etiology, and no red flag symptoms, there is a lack of support for the requested MRI of the cervical spine. MRI of the spine is a powerful tool for the assessment of the spine, with excellent visualization of the spinal cord, nerve roots, ligaments, and bone marrow.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. Findings: The physician reviewer found that MRI of the cervical spine may be appropriate for the evaluation of patients with prior cervical spine surgery, new or increasing non-traumatic cervical or neck pain, or cervical radiculopathy. Current evidence-based medical criteria for cervical spine MRI generally includes emergence of physiologic evidence of tissue insult or neurologic dysfunction, progressive neurologic symptoms, failure of conservative treatment, or clarification of anatomy prior to an invasive procedure. This patient presents with cervicalgia, paresthesia of skin, pain in upper arm, and abdominal pain. Physical examination revealed complaints of chronic joint pain throughout her body.

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 Cervical Spine, then check the rights and deadlines that apply to your plan.