Is an MRI of the spinal canal (72157 and 72158) medically necessary for a patient with a history of cervical spine fusion who complains of burning in the mid and low back?

MRI of Thoracic and Lumbar Spine is NOT Medically Necessary in This Case

Based on ACR Appropriateness Criteria, this patient does not meet established indications for MRI of the thoracic or lumbar spine, as there is no documented failure of 6 weeks of conservative treatment, no radicular symptoms with functional impairment, and no consideration for surgical intervention. 1

Rationale for Denial

Absence of Required Conservative Treatment Duration

• The ACR guidelines explicitly state that patients with subacute or chronic low back pain should only be imaged after failing 6 weeks of optimal medical management 1
• This patient's clinical documentation states the mid and low back burning "has gotten somewhat worse" since cervical surgery but provides no evidence of:
  • Duration of current symptoms
  • Specific conservative treatments attempted (physical therapy, medications, injections)
  • Timeframe of conservative management
  • Documentation of treatment failure 1

Lack of Radicular Features or Functional Impairment

• ACR criteria require pain that is "localized to thoracic back or radicular in nature" with "significant interference of daily function" 1
• The patient describes only "burning in his mid and low back" without:
  • Dermatomal distribution suggesting nerve root involvement
  • Lower extremity weakness, numbness, or radicular pain patterns
  • Bowel/bladder dysfunction suggesting cauda equina syndrome
  • Documented functional limitations in activities of daily living 1

No Surgical or Interventional Candidacy

• Imaging is only indicated when patients are considered candidates for surgery or intervention after conservative treatment failure 1
• The clinical documentation explicitly states there is "no indication the patient is being considered for invasive treatment"
• The provider's plan is simply to "follow up once those [MRIs] are complete" without any specific interventional or surgical consideration 1

Post-Surgical Context Does Not Change Indication

Adjacent Segment Disease Requires Specific Clinical Features

• While MRI is appropriate for post-fusion patients with new or progressive symptoms, this requires documentation of neurologic deficits or radiculopathy 1
• The patient's cervical fusion symptoms have resolved (no neck issues, preoperative burning pain resolved, toe numbness significantly improved)
• The mid/low back symptoms existed before surgery and represent a separate, non-acute complaint 1

Hardware-Related Complications Not Suspected

• MRI with and without contrast is indicated post-operatively when evaluating for:
  • Recurrent disc herniation versus scar tissue
  • Epidural abscess or infection
  • Hardware failure with new neurologic symptoms
  • Adjacent segment degeneration causing radiculopathy 1
• None of these complications are clinically suspected in this patient 1

Common Pitfalls to Avoid

"Lack of Recent Imaging" is Not an Indication

• The provider states "we do not have any recent imaging of these areas" as justification
• Absence of prior imaging does not constitute medical necessity for obtaining imaging 1
• Imaging must be driven by clinical indications, not simply availability of prior studies

Pre-existing Symptoms Do Not Warrant Immediate Imaging

• The patient acknowledges these symptoms "he had before surgery"
• Chronic, stable symptoms without red flags or treatment failure do not meet imaging criteria 1
• The fact they are "somewhat worse" is insufficient without documented conservative treatment attempts

MRI Findings in Asymptomatic Patients

• MRI abnormalities are frequently seen in asymptomatic individuals and do not correlate with symptom severity 1
• Obtaining imaging without proper clinical indications leads to:
  • Identification of incidental findings
  • Increased healthcare utilization
  • Potential for unnecessary interventions 1

Required Documentation for Medical Necessity

To meet criteria, the following must be documented:

1. Conservative treatment specifics:

   • Physical therapy (frequency, duration, specific modalities)
   • Medication trials (NSAIDs, muscle relaxants, neuropathic agents)
   • Activity modification attempts
   • Minimum 6-week duration of comprehensive conservative care 1

2. Radicular features if present:

   • Dermatomal pain distribution
   • Sensory deficits in specific nerve root patterns
   • Motor weakness with myotomal correlation
   • Positive straight leg raise or other provocative testing 1

3. Functional impairment:

   • Specific limitations in work, self-care, or mobility
   • Quantified pain scores and functional scales
   • Impact on quality of life despite conservative measures 1

4. Surgical/interventional consideration:

   • Specific planned intervention (epidural injection, decompression, fusion)
   • Clear statement that imaging will guide treatment decisions
   • Patient is appropriate surgical candidate if pathology identified 1

Red Flags That Would Change This Decision

Immediate MRI would be appropriate if any of the following were present:

• Progressive neurologic deficit (new weakness, sensory loss) 1
• Cauda equina symptoms (bowel/bladder dysfunction, saddle anesthesia) 1
• Suspected infection (fever, elevated inflammatory markers, immunosuppression) 1
• Known malignancy with new spinal pain 1
• Trauma with neurologic symptoms 1

None of these red flags are documented in this case. 1