Diagnosis: Pain and swelling in the left leg and left knee pain.
Treatment: Left lower extremity magnetic resonance imaging (MRI).

The insurer denied coverage for left lower extremity MRI.

The denial is upheld.

This is the case of an adult female with a history of falls, pain and swelling in the left leg and left knee pain. X-ray of the left knee following a fall was negative. MRI of the left ankle showed peroneal tenosynovitis, inframalleolar peroneus brevis tendinopathy, scarring-remodeling, evidence of sinus tarsi syndrome, posterior tibial and flexor tenosynovitis and calcaneal enthesopathy. The patient was evaluated at the hospital for left leg pain and cardiac complaints. Testing was negative for deep vein thrombosis, and the patient was instructed to schedule an MRI of the left tibia/fibula. An MRI of the left knee showed a new radial tear, mild to moderate patellofemoral compartment arthrosis and small knee joint effusion with mild synovitis; the proximal tibiofibular joint was normal. X-rays of the left foreleg showed no fracture or other acute abnormality.

The indications for an MRI are to help a physician in establishing a pain generator. There should be consistency of the clinical record with a complete history and physical examination. There should be a differential diagnosis. A course of conservative management should be provided prior to special imaging. There should be documentation in the medical record by treating practitioner of possible surgical intervention or change in treatment. There should be evaluation for "red flags". For example: tumor, infection, fracture. None of these has been considered. The facts are the injured woman has complaints to several body parts and multiple imaging studies had been completed. There is no differential diagnosis provided by physician. There is no plan for possible surgery. There were no documented physical findings to suggest pathology to the left area.

MRI for "pain" is not an established indication. Without specifics about why the doctor wants this test, it clearly is not indicated at this time.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for left lower extremity magnetic resonance imaging (MRI) is upheld. Medical Necessity is not substantiated.