Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1:  The patient is a 59-year-old male with a greater than one and one-half year history of intractable left buttock and leg pain. His pain has not responded to anti-inflammatory medication, pregabalin, and a variety of steroid injections and nerve blocks. The patient has seen multiple specialists in pain, physical medicine and rehabilitation, neurology, orthopedics, and sports medicine, but the source of his painful symptoms has not been identified. On the recommendation of his provider, the patient has requested authorization for MR neurology. The Health Plan has denied his request citing the investigation nature of the diagnostic procedure.A review of the medical records submitted for review indicates the patient has intractable left buttock pain of unclear etiology that may represent sciatica of non-disc origin. MR neurography is an MRI technique that utilizes special soft tissue coils and software which allows extra-high resolution imaging of peripheral nerves not possible with regular MRI equipment. Standard MR imaging did not reveal the source of the patients pain therefore MR neurography is medically appropriate at this juncture. Accordingly, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2:  The patient is a 59-year-old male with a long-standing history of buttock and leg pain. Various specialists and diagnostic techniques have been employed and have not identified the source of this pain. The consulting pain specialist has recommended MR neurology and the patients internist supports the recommendation. The enrollees request for authorization of MR neurography was denied by the Health Plan on the basis it is considered an investigational diagnostic procedure.MR neurography is a clinically valuable tool and has been shown to be effective in the diagnosis of acute nerve damage or nerve entrapments such as sciatica of non-disc origin. Standard diagnostic techniques have not proven to be useful for this patient, and MR neurography offers the best chance of identifying the affected nerve. Therefore, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 59-year-old male who has long-term buttock and lower extremity pain. He has been evaluated by multiple specialists and has undergone many treatments with  no prolonged relief of his symptoms. The patient had routine MR studies of the lumbar spine and pelvis in April 2006. As the etiology of his symptoms has yet to be identified, his provider recommended MR neurography for further evaluation of the sciatic nerve. The Health Plan considers this diagnostic procedure experimental and denied the requested authorization and coverage.MR neurography utilizes select MR sequences that are localized to a portion of the body (e.g. sciatic nerve) and then post-processed to produce MR neurography. Although some studies have shown MR neurography to be advantageous in the evaluation of neuropathic pain, the technology remains investigational. Additional studies are needed to determine if this approach is in fact more beneficial than routine MR imaging. For these reasons, I have determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.