Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an MRI of the right foot. We decided that the Plan does not have 
to pre-approve an MRI of the left foot.  
 
You asked the Plan to pre-approve magnetic resonance images (MRIs) of the right foot and left foot.. You say 
that you need an MRI because the regular x-ray did not show any abnormalities. You also say that you are in 
constant pain, have difficulty walking, and further treatment is impossible without the MRI. The Plan says that 
the information received did not provide clinical documentation of a 6- week trial of physician directed 
treatment in the past three months, and there was no documentation of a contact follow-up after you completed 
the treatment(s). 
 
  We decided that the Plan has to pre-approve an MRI of the right foot.  
 
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 right foot. Our reviewer 
says that the requested MRI of the right foot is reasonable. Our physician reviewer found you had a prior 
avulsion fracture of the right navicular and the possibility of ligamentous or tendon injury due to same is a real 
consideration. Our reviewer also found that even though physical therapy has not been done for this injury, the 
prior avulsion fracture and continued pain provide justification for the requested MRI of the right foot. 
 
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 right foot have been met. Therefore, we decided that the Plan 
has to pre-approve an MRI of the right foot.  
 
We also decided that the Plan does not have to pre-approve an MRI of the left foot. 
 
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 left foot. Our reviewer 
says that the requested MRI of the left foot has not been shown to be medically necessary without the 6-week 
trial of conservative management including physical therapy. Our physician reviewer found no red flag is 
present on the left side. Our reviewer also found that there is no lab work showing underlying inflammation, 
and no history of leukocytosis to imply collagen vascular disease or infection. 
 
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 left foot have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the left foot. 
 
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.