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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 also says that an MRI has proven useful in diagnosing cerebral infarctions, tumors, abscesses, edema, 
hemorrhage, nerve fiber demyelination (as in multiple sclerosis), and other disorders that increase fluid content 
of the affected tissues. MRI of the spinal canal has the advantage of noninvasive visualization of the spinal 
cord. 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. 
 
Contrast is indicated for studying the central nervous system for metastatic disease, inflammatory disease, 
recurrent tumor versus scar, differentiation of microvascular from macrovascular infarction, and selected cases 
of complex vascular disease. Within the study of the spine, contrast also is indicated to differentiate recurrent 
disc versus scar or granulation tissue, spinal cord neoplasm, any case of myelopathy, and inflammatory cord 
disease. 
 
History and clinical findings are critical factors to determine when a lumbar MRI is needed in order to 
efficiently manage low back pain and related disorders. 
 
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 
workup for metastatic cancer. 
 
  "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 
 
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 4 weeks. You can find this information in the Local Coverage 
Determination (LCD): Lumbar MRI (L37281). 
 
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.