Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer. 
Treatment: Magnetic Resonance Imaging (MRI) of the pelvis without and with contrast (code 72197). 
The insurer denied coverage for Magnetic Resonance Imaging (MRI) of the pelvis without and with contrast (code 72197). 
The denial is overturned. 

This is an adult male referred for magnetic resonance imaging (MRI) of the pelvis with and without contrast. A retroperitoneal ultrasound was performed with normal findings. The patient was seen and he was performing clean intermittent catheterization (CIC) every other day with an 18 French coude catheter initially then reduced the frequency of CIC over the past 2 weeks. He admitted to performing this approximately every 2 weeks at the time of the visit with the stream slow and with increased urgency resulting in the need to catheterize. He reported intermittent dysuria and typically needed Mycolog cream for balanitis flareups. The patient had a history of benign penile lesions and benign urethral lesions. On physical examination, the patient had mildly enlarged prostate with new nodular region on the left side of the prostate mid to apex region and measured around 2 cm in length and was firm to touch. The treatment plan included urine culture, urine microscopy, urine cytology, and ultrasound retroperitoneal complete of the kidneys and bladder. 

The patient had large leukocytes on urinalysis for which the urine was sent for micro, culture, and cytology. The patient reported occasional blood with catheterization, but this was not occurring constantly. The physician recommended a Magnetic Resonance Imaging (MRI) of the prostate with plans for Magnetic Resonance Imaging (MRI) fusion type. The cytopathology report dated showed mild numbers of neutrophils present but was negative for high-grade urothelial carcinoma. Given the patient's strong family history of prostate cancer with his father and 2 brothers, the physician wanted to continue with a further work-up. The patient also had a family history of renal cell carcinoma, pancreatic cancer, and a brother who underwent partial nephrectomy for renal cell carcinoma. He had increased urinary urge incontinence, had experienced some leaking from his right groin behind his testicle a few weeks prior, and had a history of urethral stricture secondary to stenotic hypospadias. 

Current medical literature states that Magnetic Resonance Imaging (MRI) can also be used after prostatectomy to help predict the risk of postsurgical incontinence, to evaluate postsurgical function by using dynamic voiding Magnetic Resonance Imaging (MRI) cystourethrography, and subsequently, to assess causes of incontinence treatment failure. Magnetic resonance imaging (MRI) of the prostate has evolved to be an integral part of the initial radiographic evaluation for patients at risk for prostate cancer, together with prostate-specific antigen (PSA) testing and digital rectal examination. While the physician did not specifically indicate the patient needed ultrasound fusion biopsy, there were plans for a Magnetic Resonance Imaging (MRI) to assist with biopsy of the prostate to confirm and/or rule out prostate cancer.  As such, the Magnetic Resonance Imaging (MRI) of the pelvis without and with contrast (code 72197) is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Magnetic Resonance Imaging (MRI) of the pelvis without and with contrast (code 72197) services is substantiated.