Diagnosis: Back Pain
Treatment: MRI (magnetic resonance imaging) of the lumbar spine
The insurer denied the MRI of the lumbar spine.
The determination is upheld.

This is a patient with a history of obesity, depression, and elevated blood pressure. He is requesting coverage for a magnetic resonance imaging (MRI) scan of the lumbar spine. A review of the records provided documents of treatment with anti-inflammatory medications for low back pain, as well as a referral for physical therapy. The patient reported that there was no improvement with these interventions. However, there are no records documenting an in-office physical therapy evaluation and treatment. At issue is the medical necessity of an MRI of the lumbar spine.
The requested health service/treatment of an MRI lumbar spine without and with contrast was not medically necessary for this patient.
The standard of care for ordering an MRI of the lumbar spine for low back pain includes persistent symptoms despite a 6-8-week period of anti-inflammatory medication and physical therapy. The records support the persistent symptoms and treatment with medication, but there is no medical record evidence that the patient was evaluated and treated by a physical therapist.
Therefore, based on the standard of care, as well as the peer-reviewed literature and clinical guidelines cited in the references, the MRI of the lumbar spine was not medically necessary.