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

Physician 1: The patient is a 47-year-old male who has requested authorization and coverage for a MR neurography. The patient tore his left Achilles tendon in March 2000. The tendon was repaired, but residual weakness and atrophy of the medial aspect of the gastrocnemius muscle did not recover in spite of concerted physiotherapy and muscle stimulation (most likely due to nerve damage). The patients neurologist has not been able to locate the site of the nerve damage by conventional means (i.e, electromyography) and therefore, has suggested a MR neurography. Though MR neurography may be helpful for the diagnosis of acute nerve damage or certain nerve entrapments such as carpal tunnel syndrome or other syndromes, it is not likely to result in an improved clinical outcome in the case of this patient. Even if the affected nerve were identified with great accuracy, no neurosurgical approach would be helpful after five years from the injury. Further muscle stimulation to strengthen the affected muscle is likely to be of greater clinical benefit. Therefore, I have determined that the requested MR neurography 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 47-year-old male who is status post Achilles rupture with medial left gastrocnemius weakness and atrophy. His provider has recommended the patient receive a MR neurography. The Health Plan has denied authorization and coverage for the MR neurography on the basis it is considered investigational.Review of the relevant scientific literature reveals the efficacy of MR neurography has not yet been established. Thus, this diagnostic modality remains experimental at this time. Furthermore, in the case of this patient, a thorough neurological exam and EMG/NCS studies can adequately evaluate the gastrocneumius muscle and its nerve supply. There is no evidence a MR neurography is likely to impact the management of the patients condition. As such, I have determined that the requested MR neurography 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 47-year-old male who has a history of Achilles tendon rupture and repair in 2000. Since that time, the patient has persistent weakness of the medial gastrocnemius of the left lower extremity despite physical therapy. An MR neurography has been requested for further evaluation of the patients condition. The Health Plan has denied authorization and coverage for the MR neurography on the basis it is considered investigational.Though MR neurography has been shown to be useful in anecdotal studies, this diagnostic tool remains experimental/investigational at this time. There is no literature from the American College of Radiology supporting the use of MR neurography for the evaluation of patients such as this patient. While the technology appears promising, there is insufficient evidence at this time to warrant its use in this case. Therefore, I have determined the requested MR neurography 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.