MRI Of The Cervical Spine denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MRI of the shoulder and neck.American College of Radiology (ACR) Appropriateness Criteria state that MRI may be appropriate for new or increasing non-traumatic neck pain with no red flags as initial imaging. Guidelines state that radiography of the cervical spine is usually appropriate. For new or increasing non-traumatic cervical radiculopathy with no red flags, MRI is usually appropriate as initial imaging. Evidence based medical guideline criteria for ordering cervical spine MRI generally includes emergence of a red flag, physiologic evidence of tissue insult or neurologic dysfunction, progressive neurologic symptoms, failure of conservative treatment, or clarification of anatomy prior to an invasive procedure.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging of the spine (MRI). Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Over the years, the American College of Radiology (ACR) has established appropriateness guidelines, directing appropriate evaluation of various common conditions. In 1998, an Appropriateness Criteria was established for chronic neck pain. This guideline criteria was subsequently reviewed in 2013. There are clear variations as to the clinical presentation of chronic neck pain. This patient’s presentation fits within one of the criteria guideline parameters. The variant that best describes this patient is either “Chronic neck pain, radiographs normal.

Where the denial was upheld

The patient is a 52-year-old male who has a long history of low back pain. He was previously seen by a neurosurgeon in April 2005, and his symptoms improved with conservative therapy. The patient had an MRI of the lumbar spine in April 2005, which showed degenerative disc disease at L4-5, and grade l spondylolisthesis at L5 with a disc bulge and neuroforaminal narrowing.A clinical note dated March 2006 states that the patient has pain in his upper back that radiates to his right shoulder. The note states the pain is chronic, but the exact duration is not documented. It is stated that the patient has had physical therapy, but the duration is not documented. No other conservative therapeutic measures are documented. A follow-up appointment with the neurosurgeon was made and MRIs of the cervical and thoracic spine was ordered.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the cervical spine. MRI of the spine is a powerful tool for the assessment of the spine, with excellent visualization of the spinal cord, nerve roots, ligaments, and bone marrow. However, the medical literature notes that the sensitivity of MRI leads to frequent identification of changes to the spine that are of no clinical significance. Recent studies found that guidelines recommend deferring MRI until conservative therapy has been attempted in cases with no red flag signs or symptoms. In this case, the patient presented with neck pain. However, physical examination findings did not indicate any neurological issues such as motor, sensory, or reflex deficits to support an indication for the requested MRI.

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