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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 Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.2(B). 
  
  The rules say that supportive documentation evidencing the condition and treatment is expected to be 
documented in the medical record and be available upon request for the lumbar magnetic resonance imaging 
(MRI). The patients medical record must be legible and clearly indicate the necessity and reasonableness of 
the service. Lumbar MRI abnormalities alone do not validate the need for the test without other supporting 
clinical rationale. Radiologists and/or ordering physicians should include sufficient clinical information in the 
report to justify its necessity. The clinical findings and relevant prior treatment that support the need for the 
MRI must be documented in the MRI report or clinical record and made available to the contractor upon 
request. The medical record of the referring physician must support a contemplated diagnosis or treatment 
change derived from the MRI findings. The contractor may request medical records from the referring 
physician if the radiologists documentation does not validate that the service is reasonable and necessary. You 
can find this rule in the Local Coverage Article (LCA) - Billing and Coding: Lumbar MRI (A57207) - 
Effective October 1, 2021. 
 
The rules say that magnetic resonance imaging (MRI) can: 
 
-Differentiate solid from cystic tumors, 
-Diagnose and localize spinal cord compression; 
-Diagnose syringomyelia (progressive, chronic sensory disturbance, atrophy and spasticity of the spinal cord), 
disc disease, and any altered relationship between vertebral bodies, discs, spinal cord and nerve roots; 
-Detect congenital spinal dysraphism (failure of fusion of parts along the dorsal midline of the spinal cord); 
-Provide early detection of osteomyelitis, and 
-Detect spinal cord abnormalities associated with osteomyelitis. 
 
You can find this rule in the Local Coverage Determination (LCD) - Lumbar MRI (L37281) - Effective 
October 1, 2019. 
 
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 
 
 You can find this rule in the Local Coverage Determination (LCD) - Lumbar MRI (L37281) - Effective 
October 1, 2019. 
 
The rules say that 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. You can find this rule in the Local Coverage Determination (LCD) - Lumbar MRI 
(L37281) - Effective October 1, 2019. 
 
The rules say that 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. You can find this rule in the Local Coverage 
Determination (LCD) - Lumbar MRI (L37281) - Effective October 1, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.