Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left sided sciatica.

Treatment was a CT (computed tomography, lumbar spine, without contrast material), procedure code (72131).
The insurer denied coverage for a CT (computed tomography, lumbar spine, without contrast material), procedure code (72131).

The denial is upheld. 

The patient with a history of left sided sciatica. A snapshot is provided of an Assessment/Plan that states Leg pain, left. Pain in the lower buttock down the left leg with numbness to the left foot for a few days. She can't sleep due to pain. Has a history of sciatica - states this feels very different. Pain for a few days, denies back pain, pain lower buttock and lateral hip. No edema, no calf tenderness. A computed tomography (CT) scan was ordered. #2 assessment of numbness of left foot with an impression that states some tingling of left foot, no weakness or incontinence, no edema. CT obtained. Steroid taper offered. A snapshot of the CT impression states moderate left neural foraminal stenosis at L(lumbar) 4-5 with impingement upon the traversing left S (sacral)1 nerve root "at L4-5 urinary to an extruded disc". Spondylolisthesis, chronic at L5-S1.
Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging. CT May Be Appropriate. (2)

There is lack of documentation of subjective and objective exam to necessitate the need of a CT scan according to the criteria.

The CT of the lumbar spine was not medically necessary. There is no documentation by the provider that includes subjective complaints and a comprehensive exam to show an acute onset of a neurological deficit. No red flags are noted. No acute trauma is noted. The snapshot of the CT impression states no changes at the L5-S1 which would lead one to believe that she had prior studies. One would question if she had any prior conservative treatment to indicate repeat imaging. Due to the unclear status of the patient, the CT scan is not supported by clinical guidelines or standard of care.

American College of Radiology (ACR) Appropriateness Criteria: Low Back Pain
Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging. CT Usually Not Appropriate.
Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging. CT Usually Not Appropriate.
Variant 3: Subacute or chronic low back pain with or without radiculopathy. Surgery or intervention candidate with persistent or progressive symptoms during or following 6 weeks of optimal medical management. Initial imaging. CT May Be Appropriate.
Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging. CT May Be Appropriate.
Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging. CT May Be Appropriate. 
Variant 6: Low back pain with or without radiculopathy. One or more of the following: low-velocity trauma, osteoporosis, elderly individual, or chronic steroid use. Initial imaging. CT May Be Appropriate.
Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging. CT May Be Appropriate. (2)

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a CT (computed tomography, lumbar spine, without contrast material), procedure code (72131) is upheld. Medical Necessity is not substantiated.