Magnetic Resonance Imaging Of The Shoulder denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for magnetic resonance imaging (MRI).Based on the records provided for review, the requested MRI of the right shoulder is medically necessary for the evaluation of this patient. The sternoclavicular joint is a unique saddle synovial joint and is the only connection between the upper extremity to the axial skeleton. The initial imaging study for evaluation of the sternoclavicular joint is radiographs. In the setting of shoulder pain, when radiographs are negative or inconclusive, and rotator cuff pathology is suspected, then shoulder MRI is usually appropriate after a trial of conservative management. Medical literature reveals that an MRI provides the best visualization of anatomy and pathology.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging of the shoulders. A study indicates that shoulder pain is the third most common musculoskeletal complaint in orthopedic practice. Shoulder pain is usually due to a defect of the rotator cuff and/or an impingement syndrome. Shoulder pain is a very common symptom. Disorders of the rotator cuff tendons due to wear or tear are among the most common causes of shoulder pain and disability. A SLAP (superior labral tear from anterior to posterior) lesion may also be present. Magnetic resonance imaging, magnetic resonance arthrography, and ultrasound are increasingly being used to assess the presence and size of rotator cuff tears to assist in planning surgical treatment. It is not known whether one imaging method is superior to any of the others.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right shoulder and right shoulder arthroscopy, open reduction with internal fixation (ORIF) surgery. The American College of Radiology (ACR) guidelines do not recommend MRI for the evaluation of traumatic shoulder pain when radiographs show humeral head or neck fracture. Steinhaus and colleagues discussed the complex treatment of displaced proximal humerus fractures, as its success is predicated on multiple factors. The authors noted that the majority of proximal humerus fractures may be treated non-operatively, and studies have not established which patients will benefit from surgical management.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right shoulder. Findings: Per the American College of Radiology (ACR), MRI can aid in detecting extra-articular abnormalities including osseous and soft-tissue findings that may predispose to or be the result of shoulder impingement. A study concluded that rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics. The authors noted that history and physical examination are important for excluding other causes of shoulder pain, while imaging assists in confirming the diagnosis and defining the severity of the abnormality.

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 Magnetic Resonance Imaging Of The Shoulderwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.