Pelvic MRI denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested pelvic magnetic resonance imaging (MRI for evaluation of the enrollee’s chronic low back pain). Findings: The physician reviewer found that the medical literature supports the requested pelvic MRI in this clinical setting. In this patient’s case, the treating provider is considering an assessment of ischial bursitis as the cause of this patient’s pain. Ischiogluteal bursitis refers to damage and inflammation to the bursa (small fluid filled sac) between the hamstring tendon and the pelvic bone. The main symptom is pain, and it can occur from excessive force, repetitive actions or prolonged pressure during activities such as sitting, running, kicking, climbing and jumping. It is generally treated conservatively, and is not treated surgically.

An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the pelvis.Endometriosis is an inflammatory disease in which endometrial-like tissue forms lesions outside the uterus. Its primary manifestations include dyspareunia, dysmenorrhea, chronic pelvic pain, and infertility. In general, hormonal therapies do not eliminate endometriosis. The diagnosis is made clinically in most patients. Often, pelvic examination findings correlate with laparoscopic diagnosis, however many patients diagnosed with endometriosis have normal pelvic exam findings. Ultrasonography is indicated in all patients, but MRI is said to be indicated for those patients in whom ectopic endometrial tissue was not clearly detected (Collinet, P., et al).

Where the denial was upheld

An has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis. Findings: the physician reviewer found that for diagnostic purposes, the National Comprehensive Cancer Network (NCCN), guidelines recommend pelvic MRI for patients with clinical T3-4 disease, or T1-2 disease with high risk greater than 10% of lymph node involvement. According to the submitted documentation, this patient does not meet the criteria outlined in the NCCN guidelines. The NCCN guidelines do not discuss MRI for radiation planning. Instead, MRI may be used to better select patients with intermediate risk cancer for single modality brachytherapy versus multimodality brachytherapy plus external beam radiation. This patient is diagnosed with low risk disease.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the pelvic MRI (CPT 72195) provided on 9/13/22, the lumbar MRI (CPT 72148) provided on 9/13/22, and/or the chest MRI (CPT 72146) provided on 9/14/22.According to the American College of Radiology (ACR), plain x-rays are recommended as the first imaging modalities generally used to evaluate patients with back pain. This patient underwent evaluation with a plain x-ray on 8/29/22 after reporting back pain. The result of the plain x-rays revealed only mild degenerative changes. The provider recommended MRI studies to further evaluate the patient.

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 Pelvic MRIwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.