Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve MRI of the cervical spine. We decided that the Plan does not 
have to pre-approve MRI of the thoracic and lumbar spine.  
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar 
spine.. You say that physical therapy would be a risk due to previous surgeries and existing hardware. The Plan 
says that the criteria for coverage have not been met. 
 
We decided that the Plan has to pre-approve MRI of the cervical spine.  
 
The Plan follows Medicare rules. Medicare rules say that MRIs are covered when medically necessary and 
reasonable for the diagnosis or treatment of the specific patient involved. 
 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 reviewer says that MRI 
of the cervical spine is medically necessary. Our physician reviewer found the records show that you have 
bilateral upper extremity paresthesia. Due to the history of prior extensive cervical spine fusion and bilateral 
upper extremity paresthesia, together with abnormal MRI showing cervical canal stenosis in 2014, it would be 
reasonable to go forward with MRI 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 MRIs have been met. Therefore, we decided that the Plan has to pre-
approve MRI of the cervical spine.  
 
We also decided that the Plan does not have to pre-approve MRI of the thoracic and lumbar spine. 
 
The Plan follows Medicare rules. Medicare rules say that MRIs are covered when medically necessary and 
reasonable for the diagnosis or treatment of the specific patient involved. 
 
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 of the thoracic and lumbar spine. 
Our reviewer says that MRI of the thoracic and lumbar spine is not medically necessary. Our physician 
reviewer found physical exam showed no other abnormality and plain films of the thoracic spine showed 
anterior wedging of T-12 stable since 2015. No new compression fracture and aside from pain no thoracic 
spine clinical findings. Lumbar spine showed degenerative changes at L5-S1 and no red flag on physical exam 
or plain films to forego physical therapy (PT). 
 
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 of the thoracic and lumbar spine have not been met. Therefore, we decided 
that the Plan does not have to pre-approve MRI of the thoracic and lumbar 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.