Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MRI of the shoulder and neck.American College of Radiology (ACR) Appropriateness Criteria state that MRI may be appropriate for new or increasing non-traumatic neck pain with no red flags as initial imaging. Guidelines state that radiography of the cervical spine is usually appropriate. For new or increasing non-traumatic cervical radiculopathy with no red flags, MRI is usually appropriate as initial imaging. Evidence based medical guideline criteria for ordering cervical spine MRI generally includes emergence of a red flag, physiologic evidence of tissue insult or neurologic dysfunction, progressive neurologic symptoms, failure of conservative treatment, or clarification of anatomy prior to an invasive procedure. In this case, the patient presented for initial evaluation of severe pain radiating from the neck and right shoulder to the right upper arm to the elbow. He has reported associated numbness, tingling, and weakness. Functional limitations are noted in activities of daily living and work ability. Clinical exam findings have not documented any focal neurologic deficits, but physical exams have not been provided recently due to COVID-19 circumstances. There is cervical radiographic evidence of moderate multilevel degenerative changes present, with disc space narrowing, osteophytosis, and uncovertebral hypertrophy. The patient has failed to improve with conservative treatment including activity modification, medications, and a physical therapist directed home exercise program. The patient has spoken with his primary care physician, a PM&R specialist, and a rheumatologist, all of whom have opined the diagnosis of cervical radiculopathy. Current evidence based medical guidelines would support MRI of the cervical spine based on new or increasing non-traumatic cervical radiculopathy with no red flags. Therefore, the requested MRI of the neck is medically necessary to treat the patients medical condition.ACR Appropriateness Criteria state that MRI is usually not appropriate as an initial study for atraumatic shoulder pain. Guidelines state that radiography of the shoulder is usually appropriate as the initial study. Guidelines state that MRI of the shoulder is usually appropriate as the next imaging study for atraumatic shoulder pain with suspected rotator cuff disorders when initial radiographs are normal or inconclusive. In addition to evaluating the rotator cuff, MRI can aid in detecting extra-articular abnormalities including osseous and soft-tissue findings that may predispose to, or be the result of, shoulder impingement. In this case, there is right shoulder radiographic evidence of moderate AC and mild glenohumeral joint degenerative changes. Current evidence based medical guidelines do not support MRI of the right shoulder, as there is no evidence of shoulder pathology on clinical exam, no diagnosis of rotator cuff disorder, and no discussion of impingement morphology on x-ray. Therefore, the requested MRI of the shoulder is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.