Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Diffuse large B-cell lymphoma (DLBCL), Rectal cancer.
Treatment:  CPT 74183 - Magnetic resonance imaging (MRI), a special kind of picture of the stomach area without and with contrast (dye).

The insurer denied coverage for CPT 74183 - Magnetic resonance imaging (MRI), a special kind of picture of the stomach area without and with contrast (dye).  The denial is overturned.

This is a male patient with a history of diffuse large B-cell lymphoma (DLBCL) and rectal cancer.  The patient has undergone eight computed tomography (CT) scans and four positron emission tomography (PET)/CT scans.  The treating provider has requested magnetic resonance imaging (MRI) of the abdomen as surveillance because the patient does not want to undergo CT scans due to radiation exposure.

Per Kalra et al., "Use of computed tomography (CT) in medicine comes with the responsibility of its appropriate (wise) and safe (gentle) application to obtain required diagnostic information with the lowest possible dose of radiation. CT provides useful information that may not be available with other imaging modalities in many clinical situations in children and adults.  Inappropriate or excessive use of CT should be avoided, especially if required information can be obtained in an accurate and time-efficient manner with other modalities that require a lower radiation dose, or non-radiation-based imaging modalities such as ultrasonography and magnetic resonance imaging. In addition to appropriate use of CT, the radiology community also must monitor scanning practices and protocols. When appropriate, high-contrast regions and lesions should be scanned with reduced dose, but overly zealous dose reduction should be avoided for assessment of low-contrast lesions. Patients' cross-sectional body size should be taken into account to deliver lower radiation dose to smaller patients and children. Wise use of CT scanning with gentle application of radiation dose can help maximize the diagnostic value of CT, as well as address concerns about potential risks of radiation. In this article, key concepts in CT radiation dose are reviewed, including CT dose descriptors; radiation doses from CT procedures; and factors and technologies that affect radiation dose and image quality, including their use in creating dose-saving protocols."

As per the Food and Drug Administration, "[Magnetic resonance (MR)] images are made without using any ionizing radiation, so patients are not exposed to the harmful effects of ionizing radiation."

The American College of Radiology recommends limiting lifetime diagnostic radiation exposure to 100 millisieverts (mSv).  That is equal to 10,000 chest X-rays, or up to 25 chest CT scans.  At this point, the patient has undergone 8 CT scans and 4 PET/CT scans.  This would correspond to 120 mSv, which is above the lifetime recommended threshold for an individual.  Therefore, use of alternative imaging modality would be appropriate.  The MRI can be used for gastrointestinal stromal tumor (GIST), though it is not generally used for surveillance.  However, the use of MRI is considered reasonable for this patient.  Based on the review of the medical record and literature, the requested MRI is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.
                                                   
The carrier's denial of coverage for CPT 74183 - Magnetic resonance imaging (MRI), a special kind of picture of the stomach area without and with contrast (dye) should be overturned.  The medical necessity is substantiated.