Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Elbow Pain.
Treatment: MRI (wrist, elbow or shoulder) Without Contrast, Pre-service.
The insurance denied the MRI (wrist, elbow or shoulder) Without Contrast, Pre-service.
The denial is upheld. 

The patient is a male with a history of swelling to his left elbow. He was evaluated and an X-ray was completed. His physical examination was significant for swelling to the olecranon bursa. His physician performed an additional x ray showing swelling. His physician provided a cortisone injection to the site. He was advised to return in four to six weeks. Services were provided by the PA (physician assistant). The diagnosis was olecranon bursitis.

The patient returned to his physician and reported new complaints of neck and left shoulder pain. He also had mild elbow pain. The elbow examination was normal. He was found to have limited motion to other body parts. X-rays of neck and left shoulder showed no fracture nor abnormality.  Recommendations were made for MRI (magnetic resonance image) of neck and left shoulder. PT (physical therapy) was recommended.

The patient returned to the office with continued neck and left shoulder pain. An injection of corticosteroid was provided to his left shoulder. Continuation of PT (physical therapy) was recommended.

The patient returned with continued shoulder problems. He also reported left elbow swelling. An additional aspiration was completed by the PA (physician assistant).

The patient returned for swelling to elbow. He was found to have an effusion. The PA (physician assistant) recommended MRI (magnetic resonance image) to left elbow.

No, the MRI (magnetic resonance image) is not medically necessary.

An MRI (magnetic resonance image) is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes MRI (magnetic resonance image) should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed.

The performance of the MRI (magnetic resonance image) should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically necessary.

The records show no specific conservative treatment had been provided to the man's elbow. There was a report of PT (physical therapy) but not specific to body part, duration and effect (i.e., cervical and left shoulder condition.). The diagnosis had been established. The patient has olecranon bursitis. There was consistency of complaint, physical finding, imaging and response to treatment.

There was no evidence of fracture, tumor nor other conditions with "red flag." There was no indication the patient was a surgical candidate. There was no need to clarify anatomy prior to operative intervention. The request for the MRI (magnetic resonance image) does not have credence nor is standard of care.

Per the ODG (Official Disability Guidelines), "MRI [magnetic resonance image] imaging studies are valuable when physiologic evidence indicates tissue insult or nerve impairment or potentially serious conditions are suspected like tumor, infection, and fracture or for clarification of anatomy prior to surgery."