MRI Of The Knee denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the left knee. The European Alliance of Associations for Rheumatology (EULAR) recommends the use of imaging in the clinical management of peripheral joint osteoarthritis for atypical clinical presentations. Imaging helps to confirm the diagnosis of osteoarthritis and make alternative or additional diagnoses. The clinical guidelines for imaging of knee osteoarthritis indicate that if imaging is needed, X-rays should be used before other modalities. However, in a review of current evidence and clinical guidelines, the authors noted that knee X-rays for osteoarthritis are associated with substantial drawbacks including low sensitivity and poor clinical correlation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the right knee and knee surgery for evaluation and treatment of the enrollee’s medical condition. Findings: The physician reviewer found that an MRI is supported if additional imaging is necessary or internal derangement is suspected. The American College of Radiology imaging criteria for non-traumatic knee pain state that the initial imaging examination for non-traumatic knee pain is radiography. An MRI examination for non-traumatic knee pain is indicated when the pain is persistent and conventional radiographs are non-diagnostic or when additional information is necessary before instituting treatment. Therefore, in this patient, the MRI is medically necessary as adjunctive diagnostically and potentially to affect treatment.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the right knee for evaluation of his medical condition. Findings: The physician reviewer found that the question of timing and necessity as to obtaining an MRI of the knee in the clinical setting of knee pain is critical in determining the appropriateness of the MRI. Medical literature and evidenced based studies indicate that an MRI is the most optimal means to evaluate an internal derangement; plain x-rays are of only limited value; but these medical studies show that an MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films. (Miller) As noted in a paper by McCarty and colleagues, “An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the right knee for evaluation of his medical condition. Findings: The physician reviewer found that an MRI is an optimal means to evaluate an internal derangement but the question of “when” or “whether” to obtain an MRI of the knee, in the clinical setting of knee pain, is important. As discussed by Miller “An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment for 3-6 weeks. However, MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films. Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms.

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