Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: This case involves a 45-year-old male who presents with left-sided numbness of his upper and lower extremities and to a lesser extent numbness of his face. He has a past medical history of possible sarcoidosis, monoclonal gammopathy, hyperlipidemia, hypertension, diabetes, attention deficit hyperactivity disorder (ADHD), bladder stones, and transitional cell cancer of the bladder. On physical examination, sensation was mildly decreased to light touch across the left side of his face. His sensation to vibration was also decreased on the left side of the face.The submitted records indicate the patient has had two MR studies of his brain.  In December, 2004, an MRI of the brain and MRI spectroscopy of the brain were performed. This report refers to a prior MR study of the brain from January 2004. The MRI imaging study showed a very small hyperintense focus in the left frontal white matter with non-specific appearance. The MR spectroscopy was normal. A request has now been made for a functional MRI and MR spectroscopy using 3.0 Tesla. The Heath Plan had denied this request indicating there is insufficient evidence of the efficacy of the requested diagnostic procedures.The data suggest that functional MRI is better when performed on a 3.0 Tesla unit than on a standard imaging unit with 1.5 Tesla. For MRI in general, studies have shown MRI with 3.0 Tesla to be more sensitive in identifying metastasis and white matter lesions such as those seen in multiple sclerosis. Thus, 3.0 Tesla MR imaging has increased sensitivity for such conditions and is better for performance of a functional MRI. However, it has not been shown that the increased sensitivity translates to better outcome.This specific patient has had two standard MR scans almost one year apart. Both of these studies showed a very small hyperintense focus of white matter lesion in the left frontal lobe. This was reported as non-specific and most importantly, was accompanied by a normal spectroscopy and was unchanged since the study in January 2004. At this point, another MR imaging study, even one performed with a 3.0 Tesla MR scanner, would not change the outcome or the diagnosis. This small focus of hyperintensity is probably related to the patients hypertension, diabetes, and hyperlipidemia.The patients symptoms in this case, constitute his numbness and attention deficit disorders (ADD)/attention deficit hyperactivity disorders (ADHD). These symptoms are certainly functional, but they do not lend themselves well to be studied with functional MRI since they cannot be easily turned on or off. Review of the medical literature does not reveal any well-documented study showing that functional MR imaging is useful to test a patients decreased sensation as described in this specific patient. As such, functional MRI would not result in any further information that could lead to more accurate diagnosis and treatment than the two MR studies that have already been performed.Accordingly, I have determined that the requested diagnostic procedures are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: This patient is a 45-year-old male with a history of diabetes mellitus, hypertension, hyperlipidemia, ADHD, and bladder cancer. He has sensory changes on the left side of his face and extremities that are likely due to non-specific white matter changes on MRI and cervical/lumbar radiculopathy. The patient also has neuropathy secondary to diabetes mellitus. His most recent MRI in December, 2004 showed stable non-specific white matter disease and negative spectroscopy. He has requested authorization for a functional MRI and MR spectroscopy using 3.0 Tesla. The Health Plan has denied his request.Functional MRI and MR spectroscopy using 3.0 Tesla are unlikely to add to the available clinical information in this case. In fact, functional MRI is primarily a research tool at present. In the case of this patient, there is a good explanation for the white matter changes, as this patient has multiple cerebrovascular risk factors. The changes were stable on his most recent imaging study. A repeat standard MRI would be reasonable if there is evidence the patient is experiencing progressive symptoms or findings since the last study. However, there is no indication for a functional MRI or MR spectroscopy utilizing 3.0  Tesla in this clinical setting.Accordingly, I have determined that the requested diagnostic procedures are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 45-year-old male with a medical history including attention deficit hyperactivity disorder (ADHD), learning disabilities, monoclonal gammapathy, sarcoidosis, autoimmune disorder, bladder cancer, diabetic neuropathy, polyneuropathy, hyperlipedemia and hypertension. Presently the patient has left-sided numbness in his face and extremities. According to the submitted medical records, the patients last MRI of the brain was in December, 2004. A functional MRI and MR spectroscopy using 3.0 Tesla (3.0T) magnet has been recommended. The Health Plan has denied coverage for the requested diagnostic procedures indicating they are considered investigational in this clinical setting.There is insufficient medical evidence to support the use of 3.0T functional MRI and MR spectroscopy for this patients medical condition. The patient has not had a recent MR of the brain with contrast, which would be appropriate given the patients history of white matter lesions on a prior MRI in 2004. However, an MRI of the head would provide adequate information if performed on a 1.5 Tesla unit (standard MR unit). Review of the peer-reviewed medical literature revealed no evidence that the requested diagnostic procedures are likely to be of greater clinical value than a conventional MRI scan performed on a standard unit.Based upon the information set forth above, I have determined that the requested diagnostic procedures are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.