Appeal type: Medical necessity
Decision: Upheld

Diagnosis: low back pain
Treatment: Magnetic Resonance Imaging (MRI) Lumbar Spine
The insurer denied the Magnetic Resonance Imaging (MRI) of the Lumbar Spine. The health plan's determination is upheld.

The patient is a male with a history of hypercholesterolemia and vitamin D deficiency who presented with lower back pain of 1.5 year duration. The pain radiated to both legs. There were no associated neurological symptoms, saddle anesthesia, or bowel or bladder incontinence. He had been moving a heavy motorcycle at the onset of the pain, and his work involves lifting heavy boxes. A lumbar (L) spine x-ray showed bilateral spondylosis of L5 with trace anterolisthesis of L5 on sacral (S)1. The patient's primary care physician recommended Tylenol, warm compresses, topical diclofenac, and tizanidine. Magnetic resonance imaging (MRI) of the spine was also ordered. A lumbosacral MRI with and without contrast was requested.

At issue is the medical necessity of magnetic resonance imaging (MRI) of the lumbar spine without contrast.
I uphold, in whole, the health plan's determination of medical necessity.

The requested MRI of the spine was not appropriate or a medical necessity in this patient due to the mechanical nature of the back pain, the lack of red flag symptoms, and the age of the patient (under 50 years and over 20 years).

Based on the review of the records, the patient is a male with a history of hypercholesterolemia and vitamin D deficiency who presented with lower back pain of 1.5 year duration. The pain radiated to both legs. There were no associated neurological symptoms, saddle anesthesia, or bowel or bladder incontinence. He had been moving a heavy motorcycle at the onset of the pain, and his work involves lifting heavy boxes. A lumbar (L) spine x-ray showed bilateral spondylosis of L5 with trace anterolisthesis of L5 on sacral (S)1. The patient's primary care physician recommended Tylenol, warm compresses, topical diclofenac, and tizanidine. Magnetic resonance imaging (MRI) of the spine was also ordered. A lumbosacral MRI with and without contrast was requested.

The patient had mechanical low back pain due to the physical nature of his work. He had no red flag symptoms, such as a history of cancer, unexplained weight loss, immunosuppression, prolonged use of steroids, a urinary tract infection (UTI), a fever, significant trauma (blunt), bowel or bladder incontinence, urinary retention, saddle anesthesia, a loss of anal sphincter tone, motor weakness, or vertebral tenderness on examination that would warrant radiographic investigations [1]. In the absence of any findings from the neurologic examination and no evidence of infection or cancer, imaging studies are not clinically helpful in the first 4 weeks of symptoms. The Quebec Task Force of Spinal Disorders (QTFSD) suggests that early radiographs are necessary only if the patient has neurologic deficits, fever, trauma, age older than 50 years or younger than 20 years, or signs of neoplasm [2]. The patient did not have any of these, and he had not received appropriate therapy for the said amount of time. Therefore, the MRI of the lumbar spine is not indicated or a medical necessity in this patient. The patient should be treated first with supportive care before perusing any advance imaging.