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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain stem with and without contrast material.For evaluation of headaches, most patients can be diagnosed without testing. However, some serious disorders may require urgent or immediate testing. Computed tomography (CT) or MRI should be done as soon as possible in patients with any of the following findings: thunderclap headache, altered mental status, meningismus, papilledema, signs of sepsis, acute focal neurologic deficit, or severe hypertension. (Silberstein, S.). Neuroimaging, usually MRI, should be done if patients have any of the following symptoms: focal neurologic deficit of subacute or uncertain onset, new onset headaches, age greater than 50 years, weight loss, cancer, human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS), change in an established headache pattern, or diplopia. (Silberstein, S.). The International Headache Society recommends using the International Classification of Headache Disorders, 3rd edition (ICHD3) to classify and diagnose headache disorders. In this classification, headaches are divided into two categories: primary and secondary. Primary headaches, which include migraine, tension-type headache and cluster headache, are benign. These headaches are usually recurrent and have no organic disease as their cause. Secondary headaches are caused by underlying organic diseases ranging from sinusitis to subarachnoid hemorrhage (International Headache Society). According to the ICHD3, migraines are a recurrent headache disorder manifesting in attacks lasting 472 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia (International Headache Society). A review article by Do and colleagues discusses the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. One red flag is a pattern change or recent onset of new headache. While there is a limited amount of data regarding this red flag, it has been suggested that recent change of pattern or a newly developed headache (less than three months) can be the only signs of a serious underlying etiology. A study which investigated adult patients with recent onset of a new headache or pattern change of an existing headache concluded that a recent change of pattern or a newly developed headache can be the only signs of a serious underlying etiology. A correct diagnosis is often delayed in these cases. (Do, T., et al.). Another red flag is progressive headache and atypical presentations. New or recent onset of daily or continuous headache should be concerning, especially if the pain or associated symptoms are progressive. An atypical presentation of headache is associated with increased likelihood of abnormality. A study that used MRI to evaluate patients for the primary complaint of chronic headache concluded that progressive headache and atypical headache presentation are not commonly described and defined in detail in the literature, but given that they may be associated with serious underlying pathology, they are thus considered to be red flags. (Do, T., et al.).In this case, the patient has new onset daily headaches. The description of her headaches does not fit the criteria of a primary headache disorder, such as migraines. Red flags for a secondary cause of headaches in this case are present and include the recent onset of a new headache and a progressive and atypical presentation. The standard of care in this case is to investigate further with diagnostic imaging. Therefore, magnetic resonance imaging (MRI) of the brain stem with and without contrast material is medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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.