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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of 
the specific patient involved. You can find this rule in the Medicare National Coverage Determinations 
Manual, Section 220.2(B).  
 
The rules say that Lumbar MRI may be indicated for a patient with a red-flag condition, such as a suspected 
tumor, infection, herniated intervertebral disc with nerve compression, or a major neurological problem. The 
MRI test result may be needed to evaluate these conditions to determine the need for surgery or other 
aggressive therapy, such as a work-up for metastatic cancer. 
 
"Red flags" are identified through an appropriate history plus a physical examination that typically includes 
evaluating muscle strength, limb circumference, reflexes, sensation, straight leg raise, and sitting knee 
extension tests. 
 
"Red flags" include: 
 
        Major trauma 
        Minor trauma in a potentially osteoporotic patient 
        History of cancer 
        Fever 
        Chills 
        Unexplained weight loss 
        Recent bacterial infection 
        IV drug abuse 
        Immune suppression 
        Pain that worsens when supine or at night 
        Saddle anesthesia 
        Recent onset of bladder dysfunction 
        Clinically significant or progressive neurologic deficit in the lower extremity 
        Unexpected laxity of the anal sphincter 
        Perianal or perineal sensory loss, 
        Clinically significant motor weakness, or  
        Other nerve root compromise 
 
Eighty (80) to ninety (90) percent of patients with low back pain improve one month after symptom onset even 
without treatment. Therefore, spinal imaging tests are not generally necessary during the first month of 
symptoms except when a "red flag" (suggesting a medically emergent condition) is noted on the medical 
history and physical examination. For a "non-red flag" condition, the MRI may be appropriate after 1 month of 
symptoms. 
 
For example, for a patient with low back pain syndrome where there is no known injury, history of cancer, or 
septic disorder and there are no symptoms or signs suggesting nerve root disorder or spinal cord dysfunction 
(i.e. no "red flags"), MRI will be covered only if the patient has not responded to a reasonable trial of 
conservative management lasting at least four weeks. 
 
If a patient's limitations due to low back symptoms do not improve within four weeks, findings on reassessment 
may reveal an indication for a MRI. However, since MRI changes are common in asymptomatic patients, MRI 
abnormalities alone do not retrospectively validate the need for the test without other supporting clinical 
rationale. 
 
A lumbar MRI used to evaluate uncomplicated degenerative disc disease or herniated nucleus pulposus is not 
considered medically necessary when a surgical intervention or other aggressive treatment (e.g. intervertebral 
joint injection) is not under consideration. 
 
When a lumbar MRI is ordered, Medicare expects that the information gained from the test will be used for 
medical decision-making. When the findings will not affect the treatment choices, the test is not reasonable or 
necessary. 
 
Certain uses of lumbar MRI are considered investigational and are therefore not covered by Medicare. These 
include the measurement of blood flow, spectroscopy, imaging of cortical bone and calcifications, and for 
procedures involving spatial resolution of bone or calcifications. 
 
A lumbar MRI that is a duplication of other imaging studies (such as a spinal CT scan) may be unreasonable or 
unnecessary. A lumbar MRI, however, could be complementary to a lumbar CT if there are inconclusive 
findings on a CT scan.  Conversely, a lumbar CT may be warranted following an MRI study if the MRI study is 
found to be inconclusive.  Documentation should support the medical necessity for the need for both studies.  
 
The payment for a single lumbar MRI procedure includes two (2) and three (3) sequences. 
 
Contraindications and limitations of lumbar MRI testing include: 
 
        Patients with an allergy to contrast media, 
        The effects upon a fetus are unknown at this time; therefore, pregnancy is to be handled at the discretion 
of the primary doctor, 
        When the technical component is performed without the professional component. 
 
Payment for more than one professional component (PC) of a single lumbar MRI: 
 
Medicare will not pay twice for service that is required only once to diagnose or treat an illness or injury. 
Typically, this A/B MAC will pay for only one PC. This A/B MAC may pay for a second PC when the 
additional physician's expertise is necessary and reasonable to diagnose or treat the patient, such as to clarify a 
questionable finding. The physician performing the initial PC must have a valid reason to require another 
physician's expertise, such as to interpret a confusing MRI. The second physician's knowledge and expertise 
must be significantly greater than that of the first reader, and it must contribute substantially to the 
interpretation. 
 
Multiple PCs of a single MRI in institutional settings: 
 
In hospital settings, the physicians involved with MRI interpretations should reach an agreement among 
themselves as to who should bill Medicare for MRI interpretations and reports. If the physicians involved 
cannot resolve these issues among themselves, this A/B MAC will pay for the interpretation and report that 
directly contributes to the diagnosis and treatment of the individual patient. Typically, this will be the MRI 
 
 
interpretation and report that is performed simultaneously with the evaluation and management of the patient.  
 
Each payable interpretation must include a complete, written report similar to one that is prepared by a 
specialist in the field. The content of the written report must address the relevant clinical issues, available 
comparative data, and test findings. The format of the report must be separately identifiable. It may be included 
under a separate heading within the clinical record. 
 
Multi-position MRI (reclining, standing) 
 
Medicare does not provide additional payment for multiple MRI?s such as in the reclining and upright 
positions. Bill for one unit of the MRI service. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Lumbar MRI (L37281). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.