Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) of the pelvis and MRI/MRA of the lower extremity. The Health Plan has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee who has a history of neuromuscular hamartoma (choristoma).Findings: In this patients case, the services at issue were medically necessary. While the ultimate diagnosis was a rare hamartoma, the referring provider had no way of predicting this, and it was important to exclude a space-occupying lesion, especially given the patients history of a prior nerve tumor. This diagnosis is rare, and the referring provider had no reason to suspect this diagnosis at the time of his evaluation of the patient.  Instead, the issue here is whether MRI is warranted in the evaluation of a peripheral neuropathy. The differential diagnosis of a peripheral neuropathy is extensive. A study found, Peripheral neuropathy has a variety of systemic, metabolic, and toxic causes. The most common treatable causes include diabetes mellitus, hypothyroidism, and nutritional deficiencies. The diagnosis requires careful clinical assessment, judicious laboratory testing, and electro diagnostic studies or nerve biopsy if the diagnosis remains unclear. A systematic approach begins with localization of the lesion to the peripheral nerves, identification of the underlying etiology, and exclusion of potentially treatable causes.  Most peripheral neuropathies are not related to a focal structural abnormality; however, it does occasionally happen as in this patients case.  A study found, the best means to image nerves is with MRI. A study found, In the diagnostic work-up of peripheral nerve disease, imaging studies are often used to exclude focal mass lesions or external compression and to visualize muscle atrophy. Recently, it has been recognized that magnetic resonance imaging (MRI) can identify changes in peripheral nerves and secondary neurogenic alterations in skeletal muscle.  The radiology literature supports the use of MRI in diagnosing peripheral neuropathy. A study found, MRI is increasingly being used to evaluate extracranial peripheral nerve disease in clinical practice. The objective of this study was to systematically review the accuracy of MRI in distinguishing normal from abnormal extracranial peripheral nerves. In sum, in this patients case, MRI was helpful for the evaluation of this patients medical condition.  While the ultimate diagnosis was a rare hamartoma, it was medically necessary to exclude a space occupying lesion, especially given the patients history of a prior nerve tumor. For these reasons, MRI/MRA of the pelvis and MRI/MRA of the lower extremity were medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.