Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 55-year-old female who presented for a pain management follow-up evaluation 
on 10/11/21. The patient has requested reimbursement for MRI (e.g. proton), any joint of lower 
extremity, on 10/14/21. The physician reviewer found at issue is whether MRI (e.g. proton), any 
joint of lower extremity, on 10/14/21 was medically necessary for the evaluation of this patient. 
The submitted documentation does not support the medical necessity of the service at issue. The 
American College of Radiology (ACR) appropriateness criteria note that for chronic hip pain, 
Depending on history and physical examination, imaging may not be necessary to evaluate all 
hip pain. A directed examination with a particular suspected problem may direct more specific 
targeted imaging (e.g. ultrasound for abductor tendinosis/trochanteric bursitis or spine imaging 
for referred pain). Radiographs should be obtained first in most, if not all, cases and may provide 
specific information for common disorders such as arthritis or less common disorders such as 
primary  bone  tumors  ...  Whether  the  radiographs  are  normal  or  not,  they  are  often  of 
considerable value for the selection of additional imaging techniques and for comparison with 
studies such as MRI, CT, radionuclide bone scans, and 18F-fluoride positron emission tomography 
(PET). The guidelines further note that in cases of chronic hip pain and low back, pelvic, or knee 
pathology where the goal is to exclude the hip as the source, and where radiographs are negative, 
equivocal, or showing mild osteoarthritis, After radiography, MRI is the best next test to screen 
the hip for significant pathology. Chamberlain and colleagues note that in addition to the history 
and physical examination, radiography, ultrasonography, or MRI may be needed for a definitive 
diagnosis, with radiography of the hip and pelvis recommended as the initial imaging test. Reiman 
and colleagues state, Anteroposterior pelvis and lateral femoral head-neck radiographs are the 
initial diagnostic imaging of choice-advanced imaging should be performed only when requiring 
additional detail of bony or soft-tissue morphology (e.g. for definitive diagnosis, research setting 
or when planning surgery) ... Future research should refine our current recommendations by 
determining the clinical utility of clinical examination and diagnostic imaging in prospective 
studies. In this case, the patient reported pain over the lateral aspect of the knee and hip, the 
shoulders, and lower extremities. Notes dated 10/11/21 reported that the patient sustained 
multiple injuries on the right side of the body including the hip of the right lower extremityduring 
an assault on 8/5/21. The patient reported difficulty with weight-bearing activities of the right 
lower extremity and the provider recommended MRI of the right knee and hip to rule out other 
pathologies. The records noted that prior imaging such as x-rays and CT at the hospital were 
negative for any type of fractures. However, the submitted documentation did not include clear 
documentation of initial radiographs of the right hip that were negative or equivocal to warrant 
more advanced imaging. The provider did not clearly identify what body regions were imaged 
with what specific imaging study. Given that current medical literature recommends that in 
addition to a history and physical examination, x-rays of the hip and pelvis should be the initial 
imaging test before an MRI, the service at issue was not medically indicated. Therefore, MRI (e.g. 
proton),  any  joint  of  lower  extremity,  on  10/14/21,  was  not  medically  necessary  for  the 
evaluation of this patient.