Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve MRI abdomen; without contrast material(s) (74181). We 
decided that the Plan does not have to pre-approve MRI pelvis; without contrast material(s) (72195).  
 
You asked the Plan to pre-approve the MRI, pelvis; without contrast material(s) (72195) and the MRI 
abdomen; without contrast material(s) (74181). You say that the services are medically necessary. The Plan 
says that the request does not meet the Medicare or Health Plan coverage criteria. 
 
We decided that the Plan has to pre-approve MRI abdomen; without contrast material(s) (74181).  
 
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 MRIs. Our physician reviewer 
found the requested MRI of the abdomen is reasonable since the MRI of July 27, 2022, showed a dilated 
pancreatic duct and a 9 mm cystic mass in the pancreatic tail. Despite a computed computerized tomography 
(CT) of the abdomen and pelvis September 26, 2022, showing a normal pancreas the findings on the MRI scan were described as stable with no change since 2021. Thus, likely the CT of the abdomen was a false negative 
with respect to the pancreas and surveillance of a cystic pancreatic tail mass and dilated pancreatic duct is 
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 the MRIs have been met. Therefore, we decided that the Plan has to pre-
approve MRI abdomen; without contrast material(s) (74181).  
 
We also decided that the Plan does not have to pre-approve MRI pelvis; without contrast material(s) 
(72195). 
 
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 MRI pelvis; without contrast 
material(s) (72195). Our physician reviewer found the enrollee has no pelvic symptomatology and the CT of 
September 26, 2022, showed no worrisome pelvic pathology. There is no documented medical necessity of the 
requested MRI of the pelvis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI pelvis; without contrast material(s) (72195) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve MRI pelvis; without contrast material(s) (72195). 
 
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.