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Lumbar MRI and Herniated disc

Patient: 43 year old with herniated l5/s1 disc + severe nerve root and dural sac compression Treatment: Lumbar MRI

Is Preauth Required? Preauth/Prior-auth is required for the treatment/procedure- MRI lumbar spine; w/o contrast. Programs managed by Carelon Medical Benefits Managementfor Fully Insured and Vendor Program eligible members. No authorization required for members not eligible for vendor. Initial lumbar herniated disc when ALL of the following criteria are met: Radicular pain radiculitis radiculopathy with significant functional impairment and or physical exam findings that correlate with radiculopathy or nerve root compression such as o Nerve root tension sign o Dermatomal sensory loss o Motor strength deficit myotomal o Abnormal reflex changes Documentation of nerve root compression or thecal sac impingement on MRI or other advanced imaging performed within the past 6 months that correlates with clinical findings All other reasonable sources of pain have been ruled out Failure of at least 6 weeks of conservative management.

Will the claim be denied? A claim for a lumbar MRI for a 43 year old with herniated L5/S1 disc and severe nerve root and dural sac compression will not be denied, provided that all of the criteria for initial lumbar herniated disc outlined in the Appropriate Use Criteria Spine Surgery guideline are met. These criteria include radicular pain, radiculitis, radiculopathy with significant functional impairment, physical exam findings that correlate with radiculopathy or nerve root compression, documentation of nerve root compression or thecal sac impingement on MRI or other advanced imaging performed within the past 6 months that correlates with clinical findings, and all other reasonable sources of pain have been ruled out.

When is the following treatment medically necessary for the condition specified? An MRI is medically necessary for a 43-year-old with a herniated L5/S1 disc and severe nerve root and dural sac compression. This is because MRI is a more accurate imaging option to diagnose this condition. An MRI can detect herniated discs, determine the size and location of the disc herniation, and assess the degree of nerve root and dural sac compression. The MRI results can then be used to guide treatment decisions and determine if surgery is necessary.

What are the relevant codes for the treatment? The following CPT codes are associated with lumbar MRI services for a 43 year old with a herniated L5/S1 disc and severe nerve root and dural sac compression: 72148 (MRI Lumbar Spine, without Contrast), 72156 (MRI Lumbar Spine, with Contrast), 72150 (MRI Cervical Spine, without Contrast), 72158 (MRI Cervical Spine, with Contrast). HCPCS codes associated with these services are G0296 (MRI Lumbar Spine, without Contrast) and G0297 (MRI Lumbar Spine, with Contrast).

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