MRI Of The Shoulder denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for an MRI of the left shoulder. According to the American College of Radiology, the initial appropriate imaging study in the evaluation of atraumatic shoulder pain is radiography. Radiographs can evaluate for the presence of an unsuspected fracture or dislocation, osteoarthritis, or calcific tendinitis, among other pathologies. MRI of the shoulder is appropriate when radiography studies are negative or inconclusive, and rotator cuff pathology is suspected. An MRI can detect the degree of glenohumeral chondral loss and partial or full-thickness rotator cuff tear, which is frequently associated with osteoarthritis. MRI studies can also aid in the diagnosis of extra-articular osseous or soft tissue findings that may contribute to shoulder impingement symptomatology, as well as evaluate glenoid morphology.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) services. The American College of Radiology (ACR) Indicated that although x-rays are often obtained as a baseline in the evaluation of patients with shoulder pain, an MRI is recommended regardless of the x-ray findings. An MRI of the shoulder is a highly accurate tool in the assessment of the rotator cuff. Rotator cuff tears, particularly full thickness tears, can be reliably identified using conventional MRI with high sensitivity and specificity. Tendon retraction, muscle atrophy, and fatty infiltration are associated important findings that are well visualized on MRI and predict reparability of rotator cuff tear.

Where the denial was upheld

Findings: The physician reviewer found that The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left shoulder The American College of Radiology (ACR) Appropriateness Criteria states that an “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.” The records state that this patient has a longstanding history of left shoulder arthritis with pain. However, the provider’s records do not include adequate evidence of any significant objective deficits. As per studies, “Thorough clinical examination of the shoulder includes testing the function of the rotator cuff and leads to a tentative clinical diagnosis that is the prerequisite for diagnostic imaging procedures.

Findings: The physician reviewer found that The patient has requested authorization and coverage for (1) magnetic resonance imaging (MRI) of the left hip and (2) MRI of the shoulders. In this case, recent documented clinical findings involving the left hip and bilateral shoulders are either sparse or nonexistent, and do not include previous outside records. The submitted records do not mention groin pain or document an appropriate hip examination for gait abnormalities or limited and painful range of motion. While the records noted trochanteric tenderness, hip tendonitis/bursitis is not an indication for a pelvic MRI as this diagnosis is established clinically by way of history and physical examination without necessitating imaging. MRI of the shoulder may be indicated following six weeks of provider directed treatment over three months.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for MRI Of The Shoulderwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.