MRI Of The Lumbar Spine 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 MRI of the lumbar spine. Findings: The physician reviewer found that While routine imaging for low back pain may not be beneficial, Chou and colleagues found that diagnostic imaging is indicated if a patient with low back pain has severe progressive neurologic impairments, signs or symptoms suggesting a serious or specific underlying condition are present, or is a candidate for invasive interventions. Immediate imaging is recommended for patients with severe or progressive neurologic deficits, while imaging after a trial of treatment is recommended for patients who have minor risk factors for inflammatory back disease, vertebral compression fracture, radiculopathy, or symptomatic spinal stenosis. Subsequent imaging should be based on new symptoms or changes in current symptoms.

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the lumbar for evaluation of her back pain. The physician reviewer found that the American College of Radiology (ACR) has established criteria for the evaluation of low back pain and defined several variants such as acute low back pain, post-traumatic low back pain, low back pain in cancer patients, low back pain with radiculopathy, low back pain in patients who have had prior lumbar surgery. The ACR reports that MRI is not warranted in the acute setting. However, the ACR criteria support the utility of MRI in the setting of low back pain with radiculopathy in which the patient is a candidate for surgery or other intervention.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the thoracic spine and of the lumbar spine.The submitted documentation does not support that the requested services are medically necessary. Joint guidelines from the American College of Physicians (ACP) and the American Pain Society explicitly recommend that clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain. The joint guidelines state that clinicians should reserve imaging for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination.In this case, the patient has a history of degenerative disease affecting the neck and back.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the lumbar spine. The American College of Radiology appropriateness criteria for low back pain notes that for subacute or chronic low back pain with or without radiculopathy, without red flags, or prior management or imaging, an MRI of the spine without contrast is usually not appropriate. The guidelines further note that for elderly patients, computed tomography (CT) is preferred, although MRI can be useful to evaluate for ligamentous injury or worsening neurologic deficit. Additionally, findings on MRI may not necessarily correlate with symptoms as a patient may have incidental findings on an MRI that are not symptomatic, and, conversely, may have relatively unimpressive findings on an MRI while experiencing significant 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 Lumbar Spine, then check the rights and deadlines that apply to your plan.