MRI denials in California external review

What the reviewers wrote

Where the denial was overturned

Gender: FNature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an MRI. The American College of Radiology (ACR) Appropriateness Criteria state that magnetic resonance imaging (MRI) is considered the gold standard in the evaluation of the shoulder for entities involving the glenoid labrum and rotator cuff, given its excellent depiction of soft tissue structures. In addition to evaluating the rotator cuff, 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. (ACR 2018). A study concluded rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). Findings: The physician reviewer found that there is currently considerable debate about how best to screen for prostate cancer. The fact that this patient’s PSA level is stable does not rule out prostate cancer. Prostate cancer is notoriously slow growing, and the lack of progressive elevation does not exclude a malignancy. In general, PSA levels under 4 are not considered abnormal, whereas levels over 4 are regarded as suspicious. This patient has a PSA level in the 14 to 16 range and his PSA has been persistently elevated. There are many options for therapy (radical prostatectomy, observation and monitoring, brachytherapy, external bean radiation), with no single therapy clearly advantageous, and all therapies having significant risks of complication.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) for evaluation of her medical condition. Findings: The physician reviewer found that in this patient’s case, 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 submitted documentation does not support the use of an MRI, at this time. As stated by Roudsari and Jarvik, `All of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a magnetic resonance imaging (MRI) or computed tomography (CT) scan of the upper back, lower back, neck, shoulders, and hips and Lyrica for evaluation and treatment of her medical condition. Findings: The physician reviewer found that Lyrica is not a medically necessary treatment for the patient’s chronic pain. The documentation does not demonstrate that the patient has failed other anticonvulsant medications in the same class. Gilron reviewed evidence-based literature supporting the use of gabapentin and pregabalin (Lyrica) for chronic neuropathic and early post-surgical pain. The review concluded that these medications are efficacious treatments for neuropathic and post-surgical pain.

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