Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain. 
Treatment: Cervical Spine Magnetic Resonance Image. 

The insurer denied: Cervical Spine Magnetic Resonance Image. 
The denial is upheld. 

The patient is an adult male. There is a denial letter stating the magnetic resonance image (MRI) of the cervical spine is not medically necessary. Then it states that the notes given for review did not say that the patient did six weeks of neck exercises such as physical therapy, chiropractor treatments or medically directed home exercise program in the last six months. 
X-rays of cervical spine showed degenerative change from C3-C6. A note from 6 months ago states the patient has not had physical therapy for his condition in several years. There is a follow-up for chronic neck and right shoulder pain. The pain still 
persists following physical therapy and Robaxin. Magnetic resonance image of the cervical spine was ordered. There is a follow up 4 months ago for neck and right shoulder pain. The note states the patient has just completed therapy at his facility. This was mostly for strengthening. The patient's exam shows tenderness on the trapezius muscles bilaterally. He has restricted painful range of motion of the neck. The patient has 5/5 strength. 
A note from last month states the patient presents for follow-up of chronic neck and right shoulder pain. He has been taking Robaxin. This is not helping. Baclofen was recommended. Magnetic resonance image of the cervical spine had been ordered at the last visit. The patient states he continues with exercises for the neck and shoulder. A follow-up from last month for neck and right shoulder pain states the patient is a resident at a nursing facility. The note states the patient lives at a nursing facility and has participated in physical therapy focusing on his cervical spine. It reports the patient has neck pain that radiates in the right shoulder. The note states the patient is unable to perform frequent physical therapy due to having a right below-the-knee amputation and nonhealing wound that limit him from being able to use a prosthetic leg. The note states the patient has participated in physical therapy greater than four weeks targeting the neck and entire body. Therapy is still ongoing. The note states physical therapy has been effective; it states the patient is participating in a home exercise program. The note states x-ray records were obtained, reviewed and are on file. There is no documented physical exam of the neck in this note. 

The proposed treatment is not medically necessary. 

There is nothing in the documentation to suggest the procedure is mainly for the convenience of the doctor or other healthcare provider. However, while magnetic resonance image is clinically appropriate for diagnosing conditions such as nerve root impingement of the cervical spine, the procedure is not in accordance with the generally accepted standards of medical practice. The notes state that the patient has completed a home exercise program and physical therapy, however, there is no other documentation provided that the patient was instructed in a home exercise program and there were no documented physical therapy notes demonstrating how many sessions the patient underwent and the patient's response to physical therapy. There is not documentation of objective weakness on exam, sensory deficit, or abnormal reflexes in the upper extremity. The indications of the magnetic resonance image (MRI) of the cervical spine have not been clearly elucidated.