Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the MRI of the knee. We decided that the Plan does not have to 
pre-approve the MRI of the hip and ankle.  
 
You asked the Plan to pre-approve a magnetic resonance imaging (MRI) of the hip, knee, and ankle.. You say 
that it is medically necessary to treat the enrollee's medical symptoms. The Plan says that the enrollee did not 
complete 6-weeks of provider directed treatment within the last 3 months; therefore, the requested services are 
not medically necessary. 
 
We decided that the Plan has to pre-approve the MRI of the knee.  
 
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 the MRI of the hip, knee, and ankle. 
Our reviewer says that the MRI of the knee is medically necessary. Our physician reviewer found that the 
enrollee has chronic right knee pain. The enrollee had a plain x-ray on October 21, 2020, which showed severe 
medial compartment osteoarthritis. The enrollee has failed 2 rounds of Visco supplementation as well as 2 
sessions of platelet-rich plasma injections. The enrollee is taking opiates, Gabapentin, and Lidoderm. The 
enrollee has failed conservative therapy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI of the knee have been met. Therefore, we decided that the Plan has to 
pre-approve the MRI of the knee.  
 
We also decided that the Plan does not have to pre-approve the MRI of the hip and ankle. 
 
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 the MRI of the hip and ankle. Our 
reviewer says that the MRI of the hip and ankle is not medically necessary. Our physician reviewer found that 
the enrollee has chronic right knee pain. The enrollee had a plain x-ray on October 21, 2020, which showed 
severe medial compartment osteoarthritis. The enrollee has failed 2 rounds of Visco supplementation as well as 
2 sessions of platelet-rich plasma injections. The enrollee is taking opiates, Gabapentin, and Lidoderm. The 
enrollee has failed conservative therapy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI of the hip and ankle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MRI of the hip and ankle. 
 
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.