Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine. We decided that the Plan does not 
have to pre-approve an MRI of the thoracic spine.  
 
You asked the Plan to pre-approve an MRI of the thoracic spine and the lumbar spine. You say that you are 
requesting reconsideration with medical notes and past imaging which shows moderate to severe findings. You 
say you have ordered the MRIs to see if there are any changes. The Plan says that the request is not medically 
necessary. 
 
We decided that the Plan has to pre-approve an MRI of the 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 the item/service at issue. Our reviewer 
says that the service is medically necessary. Our physician reviewer found the enrollee's symptoms of 
claudication and leg pain point to a possible lumbar origin. The enrollee has had a course of physical therapy, a 
face to face encounter afterwards and continued symptoms. An MRI of the lumbar spine is reasonable prior to 
referring the enrollee for an epidural steroid injection as planned. The enrollee has met reasonable criteria for a 
follow-up MRI of the lumbar 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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve an MRI of the lumbar spine.  
 
We also decided that the Plan does not have to pre-approve an MRI of the thoracic 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 item/service at issue. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the thoracic spine has never 
been addressed by physical therapy specifically, and there is no documentation of thoracic spine radicular 
symptoms or red flag. The x-rays showed mild degenerative change. Thus, it is reasonable to deny the MRI of 
the thoracic spine pending a course of physical therapy addressing thoracic spine issues. Therefore, the thoracic 
spine MRI has not yet demonstrated to be medically 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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the thoracic 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.