Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain.
Treatment: Magnetic resonance imaging (MRI) lumbar spine without contrast.
The insurer denied: Magnetic resonance imaging (MRI) lumbar spine without contrast.
The denial is overturned.

The patient is an adult female with a medical history of hyperthyroidism and ulcerative colitis. A clinical progress note indicated that the patient fell on her buttocks and started to experience low back pain. Motor strength and sensation were normal. A thoracic and lumbar spine radiograph was performed and indicated an anterior compression deformity at T12 (thoracic spine number twelve) that was age indeterminate. Magnetic resonance imaging (MRI) was suggested. A magnetic resonance image of the lumbosacral spine indicated a moderate compression deformity of T12 (thoracic spine number twelve) with a one millimeter retropulsion and slight effacement of the anterior thecal sac, consistent with a burst fracture. 

The requested lumbar spine magnetic resonance image was considered not medically necessary based on medial policy with the rationale that patient has not completed six weeks of conservative treatment in the past three months. This decision is being appealed.

The lumbar spine magnetic resonance image was medically necessary.
The patient is an adult female with a medical history of hyperthyroidism and ulcerative colitis. A clinical progress note indicated that the patient fell on her buttocks and started to experience low back pain. Motor strength and sensation were normal. A thoracic and lumbar spine radiograph indicated an anterior compression deformity at T12 (thoracic spine number twelve) that was age indeterminate. Magnetic resonance imaging was suggested. The magnetic resonance image of the lumbosacral spine indicated a moderate compression deformity of T12 (thoracic spine number twelve) with a one millimeter retropulsion and slight effacement of the anterior thecal sac, consistent with a burst fracture.

The medical literature supports the use of magnetic resonance image in patients where there is suspected fracture, infection or cancer and in those patients with symptoms and physical examination findings indicative of neurological compromise. This patient had normal motor strength and sensation, but did have a history of trauma secondary to fall with persistent lumbar spine pain. Radiographs of the lumbar spine did show a compression fracture of T12 (thoracic spine number twelve). A magnetic resonance image of the spine was warranted to assess the age and acuity of this fracture. While the spine was not unstable as a result of the compression fracture, a magnetic resonance image is helpful to determine the extent of the compression fracture and course of treatment depending on the acuity of the compression fracture. An acute compression fracture would be treated better with rest, relative immobility and control of pain with medication versus active loading of the spine with physical therapy. Vertebroplasty could also be a consideration for treatment and magnetic resonance image of the spine would be indicated for this procedure. Physical therapy would not be useful until the compression fracture had time to heal and become less painful.