Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested thoracic spine Magnetic Resonance Imaging (MRI) and lumbar spine Magnetic Resonance Imaging (MRI). The decision to obtain specialized cross-sectional imaging of the spine can be difficult. Pain is a very common complaint, and not all patients who have pain require Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). As a fundamental principle, any imaging study is only worthwhile if it will affect the management of the patient. In general, while plain x-rays are often performed for back pain, plain x-rays are often of little value. Apart from excluding significant anatomic abnormalities such as a scoliosis, anatomic variations, or destructive lesion, plain x-rays are generally non-contributory. As has been shown in multiple studies, incidental findings of degenerative disease or disc abnormality are exceedingly common in asymptomatic individuals. It is well known that some patients with substantial MRI findings will not have symptoms, and conversely, some patients with minimal signs on MRI will have pronounced symptoms. The American College of Radiology (ACR) has established Appropriateness Criteria to help referring physicians obtain efficient use of imaging modalities to evaluate various clinical presentations. While they have not established specific criteria for thoracic spine pain, they have established these criteria for chronic neck and low back pain. Under these criteria, MRI of the lumbar spine is rated as Usually not appropriate in the management of chronic pain without other red flags. In this case, the patient was reported to have had chronic back pain, with no indication of any red flags. There was no mention of radiculopathy, numbness, loss of reflexes, or weakness. There was also no indication that the patient had undergone an intensive physical therapy regimen, nor was there any indication that the patient had undergone an intensive trial of medications or anti-inflammatory drugs. This patient had no symptoms other than pain, which he reported having had for at least the prior two years. There was no evidence of radiculopathy, prior tumor, or infection. While it is always possible that random testing of any organ would demonstrate a significant finding, the likelihood in this case was slim. In this patient, especially considering the reported negative plain x-ray findings, the likelihood of detecting a significant abnormality that would change management was minimal. Under these circumstances, it was still worthwhile for the patient to undergo intensive conservative management first, before MRI or surgery or steroid injections would be considered appropriate. Accordingly, the thoracic spine Magnetic Resonance Imaging (MRI) and lumbar spine Magnetic Resonance Imaging (MRI) at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.