Magnetic Resonance Imaging Of The Lumbar 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…

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the middle spine and/or right knee. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic knee pain, for an adult patient with initial radiographs demonstrating degenerative changes, an MRI may be appropriate as the next imaging examination, if the patient's symptoms are not explained by the radiographic findings. In this case, the patient’s pain persists despite conservative management and were not explained by radiographic findings. Therefore, an MRI is appropriate, and he may be a surgical candidate.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The enrollee was evaluated for lower back pain and reported it began 12 years ago. The enrollee participated in physical therapy but his pain persisted. Neurology ordered a magnetic resonance imaging scan, which revealed a disc herniation. He has been using conservative treatment for his pain, but has had occasional flare-ups. The enrollee participates in home exercise, which has improved his pain. However, the enrollee reports worsening pain over the last four to five months described as sharp in nature, with occasional radiation to the posterior right hip. The pain is exacerbated by sitting, transitioning from sit to stand, and exercising. It is worse in the morning.

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for treatment of her medical condition. Findings: The physician reviewer found that in this particular patient, an MRI is not medically necessary for evaluation of the patient’s medical condition. Medical literature supports obtaining an MRI in anticipation of some sort of intervention such as surgery or facet injections. Prior to an intervention, standard medical practice is to attempt a trial of conservative treatments such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs. The patient has had a relatively short duration of symptoms; lack of disc space narrowing on plain x-rays; and a lack of documented failure of conservative treatment.

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