Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an MRI of the lower extremity (73718) (foot). We decided that the 
Plan does not have to pre-approve an MRI of the lower extremity (73721) (ankle).  
 
You asked the Plan to pre-approve an MRI of the lower extremity (73721) (ankle) and an MRI of the lower 
extremity (73718) (foot). You say that the requested MRI of the lower extremity (73721) (ankle) is medically 
necessary and the requested MRI of the lower extremity (73718) (foot) is medically necessary. The Plan says 
that the requested MRI of the lower extremity (73721) (ankle) is not medically necessary and the requested 
MRI of the lower extremity (73718) (foot) is not medically necessary. 
 
We decided that the Plan has to pre-approve an MRI of the lower extremity (73718) (foot).  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lower extremity (73718) 
(foot). Our reviewer says that the requested MRI of the lower extremity (73718) (foot) is medically necessary. 
Our physician reviewer found after careful review of enclosed information and the pertinent guidelines for this 
case, the requested MRI of the lower extremity (73718) (foot) is indeed medically reasonable and necessary for 
this enrollee. The enrollee is noted to have a rapidly enlarging subcutaneous soft tissue mass to the medial 
aspect of the left plantar arch.  The enrollee states that the lesion is tender. Physical examination reveals a large 
mass, which is firm and palpably tender. Guidelines advised that MRIs are covered when medically necessary 
and reasonable for the diagnosis or treatment of the specific patient involved. In this particular case, the MRI 
will not only help to confirm the diagnosis, but will also help in surgical planning and management if the 
enrollee is amenable to having the mass removed. Therefore, the requested MRI of the lower extremity (73718) 
(foot) is indeed medically reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower extremity (73718) (foot) have been met. Therefore, we 
decided that the Plan has to pre-approve an MRI of the lower extremity (73718) (foot).  
 
We also decided that the Plan does not have to pre-approve an MRI of the lower extremity (73721) (ankle). 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lower extremity (73721) 
(ankle). Our reviewer says that the requested MRI of the lower extremity (73721) (ankle) is not medically 
necessary. Our physician reviewer found after careful review of enclosed information and the pertinent 
guidelines for this case, the requested MRI of the lower extremity (73721) (ankle) is not medically reasonable 
and necessary for this enrollee. The enrollee is noted to have a rapidly enlarging subcutaneous soft tissue mass 
to the medial aspect of the left plantar arch.  The enrollee states that the lesion is tender. Physical examination 
reveals a large mass, which is firm and palpably tender. Guidelines advised that MRIs are covered when 
medically necessary and reasonable for the diagnosis or treatment of the specific patient involved. In this 
particular case, the lesion is noted to be localized plantar aspect of left foot. The physical examination does not 
mention that there is any pathology to the left ankle. The enrollee does not complain of left ankle pain. The 
progress note does not advise that the ankle is involved, therefore the requested MRI of the lower extremity 
(73721) (ankle) is not medically reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower extremity (73721) (ankle) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an MRI of the lower extremity (73721) (ankle).