Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Microscopic hematuria
Treatment: Pelvis magnetic resonance imaging (MRI)
The insurer denied coverage for pelvis magnetic resonance imaging (MRI)
The denial is upheld
 
This is an adult male with lower urinary tract symptoms, microscopic hematuria with  6 red blood cells per high power field (rbc/hpf), chronic obstructive pulmonary disease (COPD) and polycythemia, and prostate-specific antigen (PSA 3.5). The physician has prescribed a magnetic resonance imaging (MRI) of the prostate.

At this time, there is insufficient medical literature and national guidelines to support medical necessity for the requested imaging procedure. While the use MRI is being studied for diagnosis of clinically significant prostate cancer, further studies are needed. The clinical picture provided to evaluate for prostate cancer is not supported as an indication for the test ordered in any specialty guidelines. Therefore, the request for pelvis magnetic resonance imaging (MRI), 1 unit is not considered medically necessary for this patient.

Litwin, M. S., &amp; Tan, H. J. (2017), "When prostate cancer is suspected, tissue biopsy remains the standard of care for diagnosis. However, the identification and characterization of the disease have become increasingly precise through improved risk stratification and advances in magnetic resonance and functional imaging, as well as from the emergence of biomarkers. Multiple management options now exist for men diagnosed with prostate cancer. Active surveillance (the serial monitoring for disease progression with the intent to cure) appears to be safe and has become the preferred approach for men with less-aggressive prostate cancer, particularly those with a prostate-specific antigen level of less than 10 ng/mL (nanograms per milliliter) and Gleason score 3 + 3 tumors. Surgery and radiation continue to be curative treatments for localized disease but have adverse effects such as urinary symptoms and sexual dysfunction that can negatively affect quality of life. For metastatic disease, chemotherapy as initial treatment now appears to extend survival compared with androgen deprivation therapy alone. New vaccines, hormonal therapeutics, and bone-targeting agents have demonstrated efficacy in men with metastatic prostate cancer resistant to traditional hormonal therapy."

Merriel, S. W. D., Funston, G., &amp; Hamilton, W. (2018), "alternative tests such as multiparametric magnetic resonance imaging (mpMRI) are currently being trialled for their accuracy and safety in diagnosing clinically significant prostate cancer... Multiparametric magnetic (mpMRI) resonance imaging (mpMRI) has gained much interest in recent years, both as a diagnostic test for prostate cancer and for monitoring men with localised prostate cancer on active surveillance for signs of disease... A number of new tests and testing strategies are being trialed to improve the diagnosis of clinically significant prostate cancer. There is some evidence for mpMRI in a number of applications in prostate cancer. Recent studies suggest that mpMRI is more accurate in diagnosing prostate cancer compared to TRUS biopsy [8, 46]; that mpMRI can improve the accuracy of biopsies of suspicious prostate lesions [47]; and mpMRI may be able to better distinguish between clinically significant and clinically insignificant prostate cancer [8]. Studies are currently underway to assess the utility of mpMRI in active surveillance for men with low-grade, localised tumours [48]. All these studies so far have been conducted in secondary or tertiary level settings."     

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for pelvis magnetic resonance imaging (MRI), 1-unit is not substantiated.