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

Physician 1: The patient is a 46-year-old female who sustained an injury following a motor vehicle accident affecting her right upper extremity leading to a chronic syndrome that has not yet been diagnosed. An MRI scan of the cervical spine reveals evidence of pathology at C5-6 on the right. The patient was evaluated by a neurologist who recommended an MR neurogram to rule out a thoracic outlet syndrome. The Health Plan has denied authorization and coverage for MR neurography on the basis it is considered investigational for evaluation of the patients medical condition.The diagnosis of a thoracic outlet syndrome is best made clinically with confirmatory tests (EMG and occasionally vascular tests). A thorough neurological examination including provocative maneuvers is appropriate to rule out the diagnosis. There is no evidence MR neurography is likely to be superior to standard diagnostic methods in this case. Therefore, I have determined that the requested MR neurogram 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.Physician 2: The patient is a 46-year-old female who has a history of neuropathic pain and swelling in the right upper extremity following a motor vehicle accident. The results of a neurologic exam were normal. An MRI of the cervical spine revealed no abnormalities. The patients provider suspects thoracic outlet syndrome and has recommended MR neurography to confirm the diagnosis. The Health Plan has denied coverage for an MR neurogram indicating it has not been shown to be effective.The Health Plans denial should be upheld. Review of the relevant scientific literature reveals MR neurography remains investigational in this clinical setting. Furthermore, there is no evidence the patient has undergone standard testing such as nerve conduction velocity studies, electromyography or vascular testing. Therefore, I have determined that the requested MR neurogram 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.Physician 3: The patient is a 46-year-old female with paracervical pain and discomfort in the shoulder. She had a normal MRI of the cervical spine and her neurologist has requested an MR neurogram to confirm his clinical suspicion of thoracic outlet syndrome. The patient had sustained a cervical sprain as a consequence of a motor vehicle accident and her evaluation as mentioned has included an MRI of the cervical spine. The Health Plan has denied coverage for MR neurography indicating it is considered investigational.The Health Plans denial should be upheld. The submitted records do not include any evidence of electrodiagnostic testing. Review of the medical literature reveals a number of references with regard to imaging of peripheral nerve, brachial plexus lesions, and cervical radiculpathy. There are no references with regard to entrapment of the lower brachial plexus in the anatomy of the lower neck that would correlate clinically with the diagnosis of thoracic outlet syndrome. Thus, MR neurography is not likely to be of value in the diagnostic work-up of this patient.Based upon the information set forth above, I have determined that the requested MR neurogram 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.