Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbosacral Radiculopathy and Spondylosis of Lumbar Spine.

Treatment: Current procedure terminology (CPT) code 72148 - magnetic resonance imaging (MRI) lumbar spine without contrast

The insurer is denied coverage for CPT code 72148 - MRI lumbar spine without contrast.

The denial is upheld. 

The patient has a history of low back pain with prior lumbar magnetic resonance image (MRI).  

He was seen by Primary Care: notes indicated low back pain, not taking medication, continues physical therapy (PT) exercises at home with some improvement. Exam normal. Left back pain and leg heaviness. Last PT for eight weeks. He was unable to work due to pain. Exam notes positive left straight leg raise. He had non-steroidal anti-inflammatory drugs (NSAID)/Tylenol, PT, steroid injections. Plan to start NSAIDs, Flexeril, continue home stretching, consider PT. He was given home exercises. Back and left leg pain, saddle anesthesia and erectile dysfunction. His exam noted a positive left straight leg raise. He was doing stretching at home. He was started on gabapentin, tizanidine, and trazodone, stop ibuprofen and Flexeril, continue topical pain cream, lumbar MRI and referral to Neurosurgery. He noted a year of saddle anesthesia, intermittent foot numbness without change. It was decided that there was no change with prior PT and muscle relaxants. He was prescribed Cymbalta. He was initially seen by PT for back pain and groin numbness and functional limitations. Pain 6-10/10.

Given the favorable outcome, and often spontaneous resolution of the vast majority of low back pain symptoms, extensive imaging is usually not necessary in patients with low back pain of less than four to six weeks duration. As stated above, work-up begins with a thorough physical exam. Neurologic deficits in a focal distribution warrant further workup. In cases of low back pain that fails to resolve within one to two months, MRI is considered the gold standard in evaluating radicular low back pain. (2) Furthermore, Up to Date based on published guidelines state "Joint guidelines from the American College of Physicians (ACP) and the American Pain Society explicitly recommend that 'clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain' and reserve imaging for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination."

In this case, the patient has had ongoing back pain with positive straight leg raise over the past few months with restarting and adding medications. He recently started physical therapy and has not been seen by a provider for update. It appears he was prescribed a home exercise program, but without mention of failing the exercises after a six week period. His saddle anesthesia is ongoing for a year and is not new. Therefore, the patient should complete his therapy to see if there is any improvement prior to ordering further imaging unless there is a new neurological deficit and standard of care.  

The health plan acted reasonably, with sound medical judgment.

The insurer's denial of coverage for current procedure terminology (CPT) code 72148 - MRI lumbar spine without contrast is upheld. Medical necessity is not substantiated.