Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical spine herniated disc syndrome

Treatment: 72141- MRI (Magnetic Resonance Imaging) of neck without dye

The insurer denied coverage for 72141- MRI (Magnetic Resonance Imaging) of neck without dye.

The denial is upheld.

This is the case of an adult female with a history of hypertension, who was evaluated by her orthopedist for neck and left shoulder pain. Magnetic resonance imaging (MRI)s were ordered for her left shoulder and neck along with topical Voltaren and Zostrix. The patient returned for a follow-up at which time the MRI images were reviewed confirming cervical spine herniated disc syndrome with multilevel impingement and left shoulder derangement with high grade rotator cuff tear. A left shoulder arthroscopy was performed; the patient started physical therapy for her shoulder after her first post-operative visit. There was no mention of further prescribed treatment specific to her neck.

An MRI is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes MRI should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed. The performance of the MRI should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically necessary.

The Official Disability Guidelines cite:

"MRI imaging studies are valuable when physiologic evidence indicates tissue insult or nerve impairment or potentially serious conditions are suspected like tumor, infection, and fracture or for clarification of anatomy prior to surgery."

Similarly, Up to Date states regarding imaging in the setting of neck pain, "In the absence of red flags (table 5), imaging is not necessary in patients with mild acute or chronic neck pain that does not limit or interrupt daily activities, does not affect performance of occupation, and is easily ignored when distracted." With regard to MRI specifically, they state "MRI is used to assess appropriateness and guide localization of surgical or percutaneous needle therapy [50-53]. However, a clear delineation of the suspected location of the spinal cord level or nerve root based on the symptoms and signs is essential if the MRI results are to be useful. Abnormalities such as disk herniation, bulge, or foraminal stenosis are seen in up to 19 percent of asymptomatic individuals [6]. Consequently, MRI should be obtained, and findings interpreted in the context of a clinically suspected diagnosis."

None of these conditions were present. There would be no extenuating circumstance to warrant the study.

The medical records report that the patient had cervical and left shoulder pain. The duration was not noted. There were no prior treatments. Her physical findings were non localized. Her physician reported a diagnosis of cervical radiculopathy. She was not reported to be a surgical candidate for her neck.

These findings do not substantiate necessity for the special study. A diagnosis was likely without surgical intervention planned. There were no treatments provided prior to ordering the study. There was no documentation of physical therapy, pain management referral, traction, nor collar. There were no extenuating circumstances to substantiate necessity of MRI testing. Based on the above, 72141- MRI (Magnetic Resonance Imaging) of neck without dye is not medically necessary. 

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for 72141- MRI (Magnetic Resonance Imaging) of neck without dye is upheld. Medical necessity is not substantiated.