Are MRI scans of the cervical spine (72141) and shoulder (73221) medically necessary for a 24-year-old female with chronic migraines, headaches, shoulder and upper back pain, who has tried Floricet (butalbital, acetaminophen, and caffeine), Imitrex (sumatriptan), Tylenol (acetaminophen), Nurtec (rimegepant), Amitriptyline, and Ajovy (fremanezumab)?

Medical Necessity Determination: Cervical Spine and Shoulder MRI

Recommendation

These MRI studies are NOT medically necessary and should be DENIED. This 24-year-old patient with chronic migraine, shoulder pain, and upper back pain does not meet established clinical criteria for advanced imaging of either the cervical spine or shoulder, and the requested studies are unlikely to change management or improve outcomes.

Clinical Reasoning

Cervical Spine MRI (72141) - Not Indicated

The patient does not meet any ACR Appropriateness Criteria for cervical spine MRI:

• No neurological deficits present: The documentation shows no abnormal neurological examination findings, no radiculopathy symptoms, no myelopathy signs (no Babinski sign, no hyperreflexia, no sensory or motor deficits, no gait abnormality), and no evidence of spinal cord compression 1

• Chronic migraine with occipital headaches does NOT require cervical spine imaging: According to ACR guidelines, MRI of the cervical spine may be appropriate for cervicogenic headache to assess degenerative disease and facet arthropathy, but this patient's presentation is consistent with primary chronic migraine, not cervicogenic headache 1. The American Academy of Family Physicians explicitly states that neuroimaging is not warranted for patients with migraine and normal neurological examination, as the prevalence of significant abnormalities is only 0.2%—no higher than in asymptomatic volunteers 2

• Upper back pain without red flags does not warrant MRI: The patient has chronic shoulder and upper back pain that is work-related, with no documented trauma, no "red flag" symptoms (fever, weight loss, progressive neurological deficits, bowel/bladder dysfunction), no evidence of infection, malignancy, or inflammatory process 1

• Plain radiographs not obtained first: ACR guidelines recommend that radiographs serve as an appropriate initial imaging modality for chronic cervical pain without radiculopathy or red flags, as they screen for spondylosis, degenerative disc disease, and malalignment 1. Jumping directly to MRI without initial plain films is not supported when no red flags are present

Shoulder MRI (73221) - Not Indicated

The patient does not meet criteria for shoulder MRI:

• No documented shoulder-specific examination findings: There is no documentation of physical examination of the shoulder, no assessment for rotator cuff pathology, no evaluation for impingement signs, no range of motion testing, and no localization of pain to specific shoulder structures

• No failed conservative management: While the patient has tried multiple migraine medications (Fioricet, Imitrex, Tylenol, Nurtec, Amitriptyline, Ajovy), there is no documentation of shoulder-specific conservative treatment such as physical therapy, NSAIDs for musculoskeletal pain, activity modification, or targeted shoulder exercises

• Work-related pain suggests musculoskeletal etiology: The documentation states the shoulder and upper back pain "occurs more at work," which suggests postural or ergonomic factors rather than structural pathology requiring MRI evaluation

• No treatment plan specified: The authorization request explicitly notes "treatment plan not specified," indicating that imaging is being ordered without a clear clinical pathway for how results would change management

Key Red Flags ABSENT in This Case

The following critical indicators that would justify imaging are NOT present 2:

• No abnormal neurological examination findings
• No focal neurological symptoms or signs
• No thunderclap headache or "worst headache of life"
• No progressive worsening of headache pattern beyond baseline chronic migraine
• No headache awakening patient from sleep (documentation states "headaches do not wake him from sleep")
• No fever, weight loss, or constitutional symptoms
• No trauma history
• No marked change in previously stable headache pattern (patient has chronic migraine with 20-23 headache days per month, which is consistent with her established diagnosis)

Evidence-Based Imaging Criteria

For chronic migraine without neurological deficits:

• Studies demonstrate that patients with migraine and normal neurological examination have only a 0.2% prevalence of significant intracranial abnormalities, which is similar to the 0.4% rate in completely asymptomatic volunteers 1, 2
• The American Academy of Family Physicians recommends that neuroimaging should be considered in patients with migraine who have an unexplained abnormal finding on neurological examination, which is not present in this case 2

For cervical pain without radiculopathy:

• ACR guidelines state that in adults with chronic cervical pain without radiculopathy, trauma, or red flag symptoms, radiographs may be an appropriate initial imaging modality, not MRI 1
• MRI is usually appropriate as first-line imaging only when chronic cervical pain is accompanied by radiculopathy and no trauma or red flags 1

Common Pitfalls to Avoid

This case demonstrates several imaging overutilization patterns:

• Conflating migraine with occipital location with cervicogenic headache: Migraine commonly involves the occipital region; this does not automatically indicate cervical spine pathology requiring imaging 2

• Ordering advanced imaging without physical examination documentation: Shoulder MRI should not be ordered without documented shoulder-specific examination findings and failed conservative management

• Bypassing initial appropriate imaging: Plain radiographs should precede MRI for chronic musculoskeletal complaints without red flags 1

• Imaging without treatment plan: The American Academy of Family Physicians recommends avoiding testing if it will not lead to a change in management 2. With no specified treatment plan, these studies represent low-value care

Alternative Appropriate Management

The following steps should occur BEFORE considering advanced imaging:

1. Optimize migraine management: The patient has tried multiple medications but may benefit from adjustment of preventive therapy dosing, addition of other evidence-based preventives, or referral to headache specialist

2. Obtain plain radiographs: If cervical spine or shoulder imaging is truly needed, start with radiographs to assess for degenerative changes, alignment issues, or obvious structural abnormalities 1

3. Document thorough musculoskeletal examination: Perform and document detailed shoulder and cervical spine physical examination with specific findings

4. Trial conservative management: Implement physical therapy, ergonomic modifications for work-related pain, and appropriate analgesics for musculoskeletal symptoms

5. Reassess with specific treatment plan: If symptoms persist despite appropriate conservative management AND examination reveals specific findings, then reconsider imaging with clear indication of how results will guide treatment

Conclusion on Medical Necessity

Both requested MRI studies fail to meet evidence-based appropriateness criteria and should be denied. The patient's chronic migraine with normal neurological examination does not warrant neuroimaging 2, and the shoulder/upper back pain lacks documentation of examination findings, failed conservative treatment, or a treatment plan that would be altered by imaging results. Approval of these studies would represent low-value care that exposes the patient to unnecessary costs, potential false-positive findings requiring additional workup, and delays in implementing appropriate evidence-based migraine and musculoskeletal pain management.