Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an MRI of the Lumbar Spine. We decided that the Plan does not 
have to pre-approve an MRI of the Thoracic Spine.  
 
You asked the Plan to pre-approve an MRI of the Lumbar Spine and Thoracic Spine. You say that the 
requested MRI of the Lumbar Spine and Thoracic Spine are medically necessary. The Plan says that the 
requested MRI of the Lumbar Spine and Thoracic Spine are not medically necessary. 
 
We decided that the Plan has to pre-approve an MRI of the Lumbar Spine.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the Lumbar Spine. Our 
reviewer says that the requested MRI of the Lumbar Spine is medically necessary. Our physician reviewer 
found the member has symptomatic lumbar spinal stenosis. The member's provider has strongly suggested interventional treatments that would likely require performance of imaging (e.g. ESIs or less likely surgery). In 
such a setting it is consistent with the standards of care to perform an imaging study in order to permit 
determination on what the most appropriate course of care would be. As such, the MRI of the Lumbar Spine 
would be reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the Lumbar Spine have been met. Therefore, we decided that the 
Plan has to pre-approve an MRI of the Lumbar Spine.  
 
We also decided that the Plan does not have to pre-approve an MRI of the Thoracic Spine. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the Thoracic Spine. Our 
reviewer says that the requested MRI of the Thoracic Spine is not medically necessary. Our physician reviewer 
found the member is noted to have some back pain that localizes to their thoracic spine. However, the 
provider's notes only suggest the presence of a muscle strain. In such a setting this cannot be determined to be 
the most appropriate service or level of care which could be provided to the member. It is unclear how said 
study would help with patient management/care. In as much, the requested MRI of the Thoracic Spine would 
not be reasonable and necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the Thoracic Spine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an MRI of the Thoracic Spine. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.