Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical Spondylotic Myeloradiculopathy

Treatment: CT (computed tomography) scan of the upper spine with contrast, current procedural terminology (CPT) code 72126

The insurer denied coverage for a CT scan of the upper spine with contrast, current procedural terminology (CPT) code 72126

The denial is overturned.

The patient is an adult female who was seen by Neurosurgery and complained of balance and fine motor dexterity issues over the last several months. She also had neck pain and bilateral arm pain (left greater than right), verified by her pain management doctor. She now needs a shower chair for balance, she drops things, and her hands lock up. Her exam was normal. The doctor ordered the cervical magnetic resonance imaging (MRI) scan, the quality was poor, but the report mentioned severe stenosis above her prior fusion at cervical level C (cervical) 4-5. The plan was for a computed tomography (CT) myelogram for better quality imaging with the understanding that if her spinal cord was significantly compressed, there may be a need for surgical intervention. Further management will hinge on whether the cord is compressed or not.

The patient was seen by Pain Management via telehealth and noted that she had formal physical therapy (PT) and continues with her home exercise program. The doctor notes severe central stenosis with flattening of the cord at C4-5 above her fusion. The appeal letter states a history of anterior cervical discectomy and fusion (ACDF) with now refractory neural compression phenomenon suggestive of cervical spondylotic myeloradiculopathy. Given her prior surgery and concern for spinal cord compression, the CT was requested to better evaluate her condition. The cervical MRI noted a large disc protrusion with severe impression on the anterior thecal sac and on the anterior cervical cord, with severe disc space narrowing, severe central canal stenosis, and probable bilateral foraminal stenosis as well.

The denial stated that the patient had an abnormal MRI, so the physician requested a CT scan. In order to approve this service, there must be doctor's notes showing a specific change in the patient's treatment plan. These notes would indicate that the patient needs surgery or the best type of surgery for her. In this case, physician states that if the new imaging shows severe spinal cord compression, surgery is indicated. The patient has myelopathic symptoms with balance, fine motor control and bilateral arm pain to elbows with numbness/tingling. Her treatment depends on the CT myelogram.

The CT myelogram is medically necessary to determine a clear picture of the patient's pathology for further treatment. The pictures of her cervical MRI are of poor quality and Neurosurgery is unable to fully assess her spinal cord compression. She has myelopathic symptoms and further imaging is imperative. The doctor states that if she has severe cord compression, surgery is planned based on the CT myelogram.

National Imaging Associates (NIA) clinical guidelines for cervical CT state - Other indications for a Cervical Spine CT: 

1)	For preoperative evaluation and Cervical Spine MRI is contraindicated 
2)	CT myelogram or discogram. (1)

CT myelography best demonstrates the processes that contact, narrow, or displace the spinal cord, nerve roots, and thecal sac. As a result, one of the most common indications for CT myelography is to help evaluate the spinal canal and neural foramina in degenerative disease when the patient cannot undergo MRI because of an MRI-incompatible implanted device or when MRI images would be nondiagnostic because of extensive artifact. (2)

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient. 

The insurer's denial of coverage for a computed tomography (CT) scan of the upper spine with contrast, current procedural terminology (CPT) code 72126 is overturned. Medical necessity is substantiated.