Appeal type: Imaging
Decision: Partially Favorable

 We decided that the Plan has to pre-approve the MRI of the lumbar spine. We decided that the Plan does not have to pre-approve the MRI of the cervical spine.   You asked the Plan to pre-approve the MRI of the lumbar spine. You say that it is felt that this imaging is necessary to determine the cause of the enrollee's issues. The Plan says that there is insufficient documentation of conservative treatments. No advanced imaging is warranted until conservative therapies are tried.  We decided that the Plan has to pre-approve the 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 the MRI of the lumbar spine.   Our reviewer says that the documentation supports the medical necessity of lumbar imaging; however, insufficient documentation is provided to support the need for imaging of the cervical spine. Our physician reviewer found the enrollee has a history of a motor vehicle accident in August 2021. The enrollee is being seen by a spine surgeon in Florida who documents that the enrollee has a history of prior multilevel lumbar laminectomy. It is noted that prior physical therapy (PT), chiropractic treatment, and steroid injections were tried.   The records do show that the enrollee is experiencing weakness in his left leg, which is a reasonable indication for lumbar imaging at this time. In regard to the cervical spine imaging, there is no documentation of radicular symptoms or red flags. There has been no complete cervical x-ray series done. There is a lack of clear documentation of PT, injections, and other treatments for this condition. The records do not support the need for the cervical spine MRI at this time.   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 lumbar spine have been met. Therefore, we decided that the Plan has to pre-approve the MRI of the lumbar spine.   We also decided that the Plan does not have to pre-approve the MRI of the cervical spine.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.  As noted above, our reviewer says that the documentation supports the medical necessity of lumbar imaging; however, insufficient documentation is provided to support the need for imaging of the cervical spine.   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 cervical spine have not been met. Therefore, we decided that the Plan does not have to pre-approve the MRI of the cervical 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.