Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervicalgia
Treatment: Magnetic resonance image (MRI) of the spinal canal and contents, cervical; without contrast material (72141) (Pre-Service)
The insurer denied the Magnetic resonance image (MRI) of the spinal canal and contents, cervical; without contrast material (72141) (Pre-Service).
The denial is upheld. 

The patient is a male with cervicalgia with "radicular changes" not specifically described. The provider states that the patient has degenerative changes on cervical spine imaging (radiographs). The radiologist (who did not examine the patient) recommended cervical spine magnetic resonance image (MRI). There is no physical examination including with face to face evaluation within the last 60 days, failure within the last three months of  six week therapeutic trial, neurological evaluation, or electrodiagnostic studies. The provider did not further describe the presence of neurological with radicular symptoms. There are no labs present which suggest concern for inflammatory disease or malignancy. No constitutional symptoms have been described. Other than physical therapy (course of treatment not described) there is no description of other therapies which have been tried or failed such as analgesics, anti-inflammatories, steroids, injections, gabapentin, antidepressants, Duloxetine or other standard of care  medications for neck pain. The provider ordered a magnetic resonance image (MRI) of the cervical spine which is the subject of this review.

This procedure cannot be approved with the description of extent and length of time the patient has been symptomatic, no physical examination, no description of radicular symptoms, no abnormal electrodiagnostic changes, no description of weakness on examination, no evidence of infection with presence of constitutional symptoms, or increased leukocyte count, no evidence of inflammatory disease without extended post rest stiffness, psoriasis, inflammatory bowel history, increased erythrocyte sedimentation rate or c-reactive protein, or other abnormal relative blood results. There is no description of extent and length of physical therapy trial and when it was conducted. There is no description of other failed standard of care reasonable therapeutic interventions such as non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, medications such as Lyrica, gabapentin, Cymbalta, epidural or facet injections within the last three months for a six week period of time. Having degenerative changes on radiographs in a male without further description of clinical presentation is inadequate to qualify a magnetic resonance image (MRI) study of the cervical spine as being medically necessary.

As per Childress, et al, "Treatment of mechanical or nonneuropathic neck pain includes short-term use of medications and possibly injections. However, long-term data for these interventions are limited. Acupuncture and other complementary and alternative therapies may be helpful in some cases. Advanced imaging and surgical evaluation may be warranted for patients with worsening neurologic function or persistent pain."

Also, as per Cohen, et al, "Muscle relaxants and non-steroidal anti-inflammatory drugs are effective for acute neck pain, and clinical practice is mostly guided by the results of studies performed for other chronic pain conditions. Among complementary and alternative treatments, the strongest evidence is for exercise, with weaker evidence supporting massage, acupuncture, yoga, and spinal manipulation in different contexts." The provider has not adequately described the clinical situation, provided a thorough examination or described reasonable therapeutic interventions.

No, the proposed test is not medically necessary.

As per the plan definition, a therapy is considered medically necessary when it meets ALL of the following criteria:

1) In accordance with generally accepted standards of medical practice
(NOT MET) 2) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease (NOT MET) 3) Not primarily for the convenience of the patient, physician, or other health care provider (NOT MET)

For the aforementioned reasons including no included or good recent documented physical examination or documentation of radicular symptoms with objective findings and no description of an adequate trial of therapy for six weeks within the last three months, the requested magnetic resonance image (MRI) evaluation of the cervical spine is not medically necessary and the plan determination was sound.