Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain

Treatment: Thoracic spine MRI (magnetic resonance imaging)

The insurer denied coverage for thoracic spine MRI (magnetic resonance imaging)

The denial is upheld

This case involves a female who presented to the physician's office complaining of back pain described as sharp and shooting in nature. She endorsed lower back pain with radiation to the left lower extremity, and claimed symptoms were aggravated with bending, walking, and prolonged sitting and standing. Symptoms were unrelieved with rest, ice, acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), prescription medications, or muscle relaxants. She tried physical therapy, exercises, stretching, a back brace, and lifestyle modification without significant relief. X-ray imaging obtained previously noted apparent osteopenia without vertebral compression. There was exaggerated thoracic kyphosis and mild multilevel thoracic disc space narrowing. Her examination noted that her pain level was 7/10 (on a pain scale of 1-10). She had tenderness throughout the thoracic spine region, with the majority of her abnormalities located in the low back. She had tenderness noted over the lumbar spinous process, over the lumbar facet joints, at the right quadratus lumborum muscle, left quadratus lumbar muscle, right and left paravertebral muscles, with trigger points noted over the latissimus dorsi, quadratus lumborum, erector spinae, gluteus maximus, and Multifidus.  She had tenderness over both sacroiliac joints and pain was elicited during lumbar passive extension, passive right and left lateral bending, with facet loading bilaterally negative for producing lumbar pain. She had a positive straight leg raise test bilaterally, but no muscle atrophy, 5/5 strength in the lower extremities, intact sensation, and normal reflexes. The treatment plan stated that an MRI of the lumbar spine was being reviewed and the patient was being referred for MRI of the thoracic spine. The patient received a notice of denial regarding coverage for thoracic spine MRI claiming that clinical notes are needed showing 6 weeks of exercises that the patient performed at home to include the total number of days per week the exercises were performed, much time per day was committed to the exercises, and a record that the patient's pain did not improve. This review pertains to the denial of coverage for a thoracic spine MRI.   

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Literature states that thoracic MRI is an important clinical role, both as a problem-solving tool and in an increasing array of clinical indications.  In the case of this patient, the information provided for the review did not support that she had specific complaints pertaining to the thoracic spine. The evidence suggested that she was suffering more from low back related issues.  While there was tenderness noted over the thoracic region, there were no significant findings that would support the need for advanced imaging. As such, the thoracic spine MRI (magnetic resonance imaging) was not considered medically necessary for this patient. The prior determination is upheld.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a Thoracic Spine MRI (magnetic resonance imaging) is upheld. Medical Necessity is not substantiated.