Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Neuropathy.
Treatment:  Abdomen and pelvic CT.
Then insurer denied the abdomen and pelvic CT.  The denial is upheld.

The CT of abdomen and pelvis was not medically necessary. 

The patient is a female.  The specific request is regarding a CT of abdomen and pelvis.

The external appeal application indicates that there is a request for CT scan of abdomen and pelvis as part of approved diagnosis process at Mayo Clinic, with no further explanation.

A letter indicates that the patient indicated that the CT scan was for cancer screening, given the rapidly progressive neuropathy.

There is a CT of abdomen that indicated no evidence of lymphoma or other malignancy of the abdomen or pelvis.

The note from Dr. Do Campo, neurology, indicates the patient was being seen with a 10-year history of bilateral knee pain and a 20-year history of intermittent left sciatic pain.  She reportedly began to experience intermittent numbness in both feet, left worse than right, about two years ago, with the note, "both feet felt like cement."  Over the past summer, she began to experience shooting pains and numbness of the right big toe and the bilateral foot and thinks that weakness of the left foot is continuing to progress.  

The patient reportedly had an EMG (electromyelogram) study less than a year prior to the MRI that was reported to be consistent with a sensory motor axonal peripheral neuropathy, with possible superimposed left sciatic neuropathy.  She was subsequently placed on gabapentin.  She reportedly had low vitamin B12 levels, and replacement was initiated.  She reportedly has been wearing an AFO (ankle foot orthosis) since late 2018.  

The patient had a repeat EMG study about six months prior to the MRI under review that showed findings consistent with multiple lumbosacral radiculopathies involving L5-S1 nerve roots.  Laboratory investigation was performed, all of which was "unremarkable."  Oligoclonal bands were absent.  Myelin basic protein, CSF (cerebrospinal fluid) was normal.  Other CSF measures were normal.

The patient had an MRI of thoracic spine showing a bulging disc at T5-6 causing compression of the ventral cord without associated spinal cord signal abnormalities.  Physical exam documented Romberg slightly positive.  Gait was unsteady with bilateral left greater than right steppage component.  Overall assessment was question of length dependent peripheral neuropathy versus multiple lumbosacral radiculopathies versus polyradicular neuropathy, with history of intermittent left-sided sciatica pain for 20 years and bilateral foot numbness and weakness, gait symmetry, left worse than right.  The plan of care was to perform a nerve conduction study.  The patient was recommended for CT scan of chest, abdomen, and pelvis to exclude underlying occult malignancy or lymphoma, MRI of the bilateral lumbosacral plexus to evaluate for abnormal signal.

There are Magellan National Imaging Associates Guidelines for CT abdomen.  It indicates that it is supported for conditions including evaluation of suspicious known mass/tumors, surveillance of such, evaluation of organ enlargement, suspected infection or inflammatory disease, evaluation of known infection or inflammatory disease, vascular disease or evaluation of trauma.

The available medical records provided for review do not support the medical necessity for request of CT abdomen and pelvis with the noted condition.

The available medical records report condition of polyradiculopathy versus peripheral neuropathy per electrodiagnostic study, with all other laboratory testing being negative.  The available medical records provided for review do not identify any suspicion of underlying malignancy or other symptoms consistent with malignancy.  There is no indication of infection or other structural etiology for a peripheral neuropathy that would be in support of performance of a CT abdomen and pelvis.