Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain

Treatment: Lumbar Spine MRI (Magnetic Resonance Imaging -pictures of inside the lower spine)

The insurer denied coverage for Lumbar Spine MRI (Magnetic Resonance Imaging -pictures of inside the lower spine.)

The denial is upheld.

This is a patient with a history of back pain. Based on the submitted records the patient was complaining of low back pain. The pain was diagnosed as sacroiliitis and the patient was referred to Physical Therapy (PT). An X-ray of the sacroiliac (SI) joints was reported as negative. Subsequent notes detail the response to treatment.  As of a prior office note, the patient was not having back pain and was continuing their stretching exercises. The note states that PT significantly helped the patient's low back pain. The patient was having calf spasms and calf pain which was already noted. An exam noted lumbar flexion and extension were normal and the patient's gait was normal. The patient's strength was also normal. Records also show that electromyelogram (EMG)/nerve conduction (NC) studies were normal. The plan stated on the visit included  "magnetic resonance imaging (MRI) L (lumbar) spine without contrast."

The appeal letter states the patient had 10 visits of physical therapy and additional chiropractic visits without benefit; however, this is inconsistent with the prior notes. The previous denial was based on a lack of documentation that the patient trialed/failed physical therapy. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      

The requested service: Lumbar Spine MRI (Magnetic Resonance Imaging -pictures of inside the lower spine) is not considered medically necessary for this patient.

In this case, the MRI would not be medically necessary. 

As per UptoDate "Patients with persistent symptoms due to a lumbosacral radiculopathy or spinal stenosis who have not responded to conservative treatment and who are candidates for and interested in invasive therapies (e.g., surgery or epidural injection for radiculopathy) should have an MRI for further evaluation and be referred for consideration for these therapies."

In this case, records indicate resolution of the patient's back pain and, in addition, no plans regarding further back pain treatments are noted. In fact, the issue now seems to be related to calf spasms. This does not support the need for an MRI of the patient's lumbar spine. 

"Routine acute low back pain (LBP) is usually a benign, self-limiting condition that does not warrant evaluation with any imaging modality. Advanced imaging modalities such as computed tomography (CT) and MRI can provide useful clinical information if used correctly in patients with radiculopathy that unresponsive to conservative management, myelopathy, neurogenic claudication, or patients with "red flag" symptoms. A thorough history and physical exam is essential to identifying patients who would most benefit from advanced imaging. Plain films are insensitive to many pathologies. Non-contrast CT is the initial study of choice if a fracture of the spine is suspected. MRI is the gold standard diagnostic imaging modality for many disease states associated with LBP, with use of intravenous gadolinium contrast reserved for patients in whom infection, malignancy, or postoperative sequelae are suspected. In patients who cannot safely undergo MRI, CT with or without myelography can be considered as a less sensitive alternative diagnostic imaging tool" (Rao D, et al 2018).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for requested service: Lumbar Spine MRI (Magnetic Resonance Imaging-pictures of inside the lower spine) is not substantiated.