Magnetic Resonance Spectroscopy denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: This case involves a 35-year-old male with a high-grade glioma status post two surgeries, chemotherapy, and radiation. The patient is currently stable, but carries a very guarded prognosis. His neurosurgeon and neuro-oncologist believe a magnetic resonance spectroscopy (MRS) is needed to assist in planning further treatment. The Health Plan has denied coverage for an MRS indicating there is insufficient peer-reviewed evidence demonstrating the accuracy of MRS is superior to alternative diagnostic modalities.MRS is now widely used for the treatment planning of gliomas. There is copious recent literature supporting its use in this clinical setting. This patient has a high-grade glioma; MRI alone is likely to be equivocal. Therefore, an MRS is medically appropriate and within the standard of care.

Nature of Statutory Criteria/Case Summary: The enrollee’s parent has requested authorization and coverage for magnetic resonance spectroscopy. Findings: Three physician reviewers found the requested MRS is likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy. Mitochondrial diseases are disorders of mitochondrial respiration resulting in defective energy production which typically manifest in systems with high energy demands, such as the central nervous system. Diagnosis is challenging because symptoms may affect any system and are typically non-specific. Structural magnetic resonance imaging (MRI) and functional brain imaging methods including MRS, diffusion-weighted imaging, and perfusion MRI, have been instrumental in acquisition of knowledge about mitochondrial disorders in a non-invasive fashion.

Where the denial was upheld

Physician #1: The patient is a 47-year-old female with a history of headaches, nausea, weight loss and a pineal cyst verified on MRI. Provider opinions differ, but the pineal cyst may be slightly larger on a follow-up scan. The patient has consulted with several specialists, and the general consensus is that the pineal cyst is a benign lesion. The consulting neurosurgeon recommends follow-up MRI and MRS to monitor the cystic lesion. The Health Plan has denied the patient’s request for authorization of the MRS, citing the investigational nature of the diagnostic procedure in this clinical context.An MRS is not the standard test for on-going evaluation of a likely benign process such as a pineal cyst. Serial MRIs as deemed necessary by the neurosurgeon are the most appropriate approach. The requested MRS is not likely to alter the care and management of this patient’s condition.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computed tomography (CT) scan or magnetic resonance spectroscopy (MRS) or angiography and magnetic resonance angiography (MRA) scan. The Health Plan has denied this request indicating that the requested diagnostic procedures are not medically necessary for evaluation of the enrollee’s dizziness. The requested for CT scan, MRS or angiography and MRA scan are not medically necessary for evaluation of the patient’s medical condition. In this case, the patient has a history of dizziness without evidence of other neurologic deficits. Symptoms have been present for at least four years, and the patient has been seen by a neurologist, who did not detect an underlying disease. In addition, the patient underwent an MRI of the brain in 2016 which was negative.

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