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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 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 
Intravenous (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 computerized tomography (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. You can find this information in Medicare's Local Coverage Determination (LCD): 
Lumbar MRI (L34220). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.