Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine (CPT 72141) and/or MRI of the lumbar spine (CPT 72148). With regard to the requested lumbar spine MRI, Srinivas and colleagues reported on a systematic review of the literature and found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging versus usual care. Furthermore, the authors noted that, high-quality consistent evidence shows that imaging patients with acute low back pain of less than six weeks duration and no red flag symptoms results in no clinical benefit but is associated with harms. Wang and colleagues stated that, most acute episodes of low back pain are self-limiting, and imaging has limited utility because most patients with low back pain have nonspecific findings on imaging studies. In addition, the American College of Radiology (ACR) does not recommend any imaging of acute low back pain with or without radiculopathy in the absence of prior management or red flags such as acute neurologic symptoms, cancer, and infection. For patients with subacute or chronic low back pain with or without radiculopathy, MRI is recommended if there is persistent or progressive symptoms following six weeks of optimal medical management. When the back pain is suspected to be secondary to trauma, additional imaging generally appropriate. For this patient, the most recent medical evaluation did not report the nature of the patients low back pain symptoms. There is no indication that the patients pain could be due to trauma. The clinical notes suggest that the patients symptoms are stable. Therefore, the requested MRI of the lumbar spine (CPT 72148) is not medically necessary for evaluation of this patient. With regard to the requested cervical spine MRI, Cohen and colleagues reported on a systematic review of the literature. The authors stated that MRI is characterized by a high prevalence of abnormal findings in asymptomatic individuals but should be considered for cases involving focal neurologic symptoms, pain refractory to conventional treatment, and when referring a patient for interventional treatment. The ACR suggests that MRI of the cervical spine without IV contrast is generally appropriate in the work-up of patients with chronic cervical or neck pain in the absence of neurologic findings for whom a radiograph shows degenerative changes. This patient had cervical spine radiographs. These imaging studies showed mild multilevel degenerative changes. This patient has ongoing neck pain documented in the chart. The most recent clinical visit indicates the presence of neck pain as well as stable cervical radiculopathy. Due to the documented chronicity of pain as well as recent radiographs showing degenerative changes, MRI of the cervical spine without IV contrast is medically necessary for evaluation of the patients medical condition. Given these findings, the requested MRI of the cervical spine (CPT 72141) is medically necessary for evaluation of this patient while the requested MRI of the lumbar spine (CPT 72148) is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in radiology with subspecialty certification in interventional radiology and diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.