Upper and Lower Extremity Magnetic Resonance Imaging (MRI) - Medicare Advantage (Revised)

By June 30, 2026: Billing and clinical teams must implement the new medical necessity criteria for all upper and lower extremity MRI requests. Specific requirements: (1) Coding/Billing Team: Update billing system templates and prior authorization rules to enforce the mandatory first-line imaging requirement (ultrasound or x-ray documentation must be present before MRI approval). (2) Prior Authorization Staff: Review all pending and future MRI requests against the expanded clinical indication list (40+ covered indications including rotator cuff pathology, labral pathology, meniscal disorders, bone infections, soft tissue masses, trauma, suspected occult fractures, and post-operative evaluations). (3) Provider Education: Distribute the specific covered indications to orthopedic, sports medicine, and primary care providers; emphasize that MRI requests without documented first-line imaging or clinical indication from the approved list will be denied. (4) EMR/Documentation: Ensure provider encounter templates prompt for documentation of completed first-line imaging and the specific clinical indication. Consequence: MRI claims submitted without evidence of first-line imaging completion or without meeting one of the specified clinical indications will be denied as not medically necessary.