Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve the MRI. We decided that the Plan does not have to pre-approve the CT scan.
You asked the Plan to pre-approve the MRI. You say that the clinical documentation provided supports the need for the radiology services being requested. The Plan says that there are no results of prior imaging showing evidence that the enrollee's condition has progressed or recurred. The Plan says that there is no evidence that the requested studies would affect how the doctor is managing the enrollee's condition.
We decided that the Plan has to pre-approve the MRI.
The Plan follows 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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee's liver function tests were in the normal range on July 30, 2021. Previous imaging from April 6, 2021, showed stable postoperative and post ablation changes to the right lobe without evidence of local recurrence. There are unchanged perfusional changes and there is dilation in the atrophied right lobe. There is a stable 1.2 cm arterially enhancing lesion dome segment 4a, and no new liver lesions. Our physician reviewer found that this could possibly be early hepatocellular carcinoma (HCC) versus dysplastic nodule. A CT with contrast done on August 30, 2019, showed nonspecific mediastinal and hilar lymph nodes up to 10mm. There was cirrhotic hepatic morphology, post central hepatectomy. There was indeterminate subcentimeter hypervascular foci right hepatic lobe and moderate paraseptal emphysema. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve the MRI.
We also decided that the Plan does not have to pre-approve the CT scan.
The Plan follows Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found results of prior imaging have not shown evidence that the enrollee's condition has progressed or recurred. A CT scan of the chest would not affect how the enrollee's providers are managing his condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the CT scan.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.