MRI Of The Brain denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain (CPT 70553). Dizziness is a nonspecific term often used by patients to describe symptoms. Furman and colleagues explain that vertigo is one type of dizziness, and that other symptoms that patients may identify as dizziness include presyncopal faintness, disequilibrium, and nonspecific or ill-defined light-headedness. The authors further note that patients often experience vertigo as an illusion of motion, the most common being a spinning sensation, although vertigo may also be a sense of swaying or tilting.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine (CPT 72156), MRI of the thoracic spine (CPT 72146), and/or MRI of the brain (CPT 70553). The patient has a neurological examination suggestive of multiple sclerosis. The patient demonstrated weakness after vigorous exercise. The patient demonstrated shaking of the neck and knee which are suggestive of spasms. These findings are suggestive of demyelinating disease as well as myelopathy. Thus, the requested MRI of the brain, cervical and thoracic spine are indicated as the patient has demonstrated symptoms in both the upper and lower locations in the body. The imaging with and without contrast is appropriate to assess the patient for active disease.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to a tertiary level facility, a referral to a neurosurgeon and a second magnetic resonance imaging (MRI) of the brain. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a history of pineal gland cyst. Findings: Based on the documentation provided, the requested services are not medically necessary for the evaluation and treatment of this patient’s medical condition. This patient has a 9 mm cyst of the pineal on an MRI scan. He has not had any significant neurologic symptoms nor has he had any objective neurologic findings on examination. There were no other abnormalities on his MRI scan: no mass effect, no hydrocephalus and no evidence of increased intracranial pressure.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for magnetic resonance imaging (MRI) of the brain. According to the American College of Radiology (ACR), in the setting of brief episodic vertigo with a normal neurological examination, MRI of the brain is considered usually not appropriate. In this case, the patient’s neurological examination was normal and the symptoms had been present for less than a week. Therefore, MRI was not indicated. Regarding the patient’s right ear pain radiating to the temporal region, there was clinical suspicion for muscle spasm. According to the ACR, in the setting of primary tension type headache with a normal neurological examination, MRI of the brain is considered usually not appropriate.

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 Of The Brain, then check the rights and deadlines that apply to your plan.