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Date Printed: October 20, 2017: 02:05 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-70540-10

Original Effective Date: 07/01/07

Reviewed: 02/26/15

Revised: 03/15/15

Subject: Functional Magnetic Resonance Imaging (fMRI)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Update    

DESCRIPTION:

Before neurological surgery for seizure disorders or resection of brain tumors, localization of certain areas of the brain, such as language and motor centers (referred to as “eloquent areas”), it is important to minimize or avoid damage or disruption to these areas. There is increased potential for damage or disruption of structures adjacent to the area of surgical interest. There are several methods that may be used to identify eloquent areas of the brain, including Wada test and direct electrical stimulation. Both of these tests are invasive and require involvement of various specialists.

Functional magnetic resonance imaging (fMRI) is proposed as a noninvasive alternative method for location of eloquent brain areas. Functional MRI allows regional mapping of human cognitive functions such as motor skills, vision, language, and memory function. Functional MRI is accomplished by imaging the active patient during the performance of specific tasks. Functional MRI uses sequences based on T2-weighted blood oxygen. Images are collected as various activities are conducted. Laterality indices are calculated, reflecting the interhemispheric difference between activated volumes in the left and right hemispheric regions of interest. These studies are often done on MR scanners with field strengths of 1.5 Tesla or greater. The functional MRI images are processed by computer and interpreted by a physician. The information from the fMRI may be used in neurosurgical planning.

POSITION STATEMENT:

Functional MRI (fMRI) meets the definition of medical necessity in the preoperative evaluation of members with seizures or brain tumors who are candidates for neurosurgery when the lesion is in close proximity to an eloquent area of the brain (e.g., controlling verbal or motor function) and testing is expected to have an important role in assessing the spatial relationship between the lesion (mapping lesion) and eloquent brain area.

Functional MRI (fMRI) is considered experimental or investigational for all other applications, as there is insufficient clinical evidence to support the use of functional MRI (fMRI) for all other applications. There is a lack of clinical data to permit conclusions on efficacy and net health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

70554

Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration

70555

Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing

96020

Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (i.e., psychologist), with review of test results and report

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report functional MRI:

Blood oxygen level dependent magnetic resonance imaging (MRI)
fMRI
Functional MR Imaging

REFERENCES:

  1. ACR-ASNR Practice Guideline for the Performance of Functional Magnetic Resonance Imaging of the Brain (fMRI), 2007.
  2. Adolfsdottir S, Sorensen L, Lundervold AJ. The attention network test: a characteristic pattern of deficits in children with ADHD. Behavioral and Brain Functions 2008, 4:9 doi: 10.1186/1744-9081-4-9.
  3. Aron Ar, Schlaghecken F, Fletcher PC. Inhibition of subliminally primed responses is mediated by the caudate and thalamus: evidence from functional MRI and Huntington’s disease. Brain 2003; 126(3): 713-723.
  4. Blue Cross Blue Shield Association Functional Magnetic Resonance Imaging Medical Policy 6.01.47, 06/14.
  5. Bookheimer S. Pre-surgical language mapping with functional magnetic resonance imaging. Neuropsychology Review 2007; 17(2): 145-155.
  6. Feldman HH, Jacova C, Robillard A. Diagnosis and treatment of dementia: 2.Diagnosis. Canadian Medical Association Journal 2008; 178 (7): 825-836.
  7. Filipek PA, Accardo PJ, Ashwal S et al. Practice parameter: Screening and diagnosis of autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society Neurology 2000; 55:468-479.
  8. Fleisher AS, Houston WS, Eyler LT. Identification of Alzheimer Disease Risk by Functional Magnetic Resonance Imaging. Archives of Neurology 2005; 62(12): 1881-1888.
  9. Lee CC, Ward HA, Sharbrough FW et al. Assessment of Functional MR Imaging in Neurosurgical Planning. American Journal of Neuroradiology (AJNR) 1999; 20(8): 1511-1519.
  10. Medina LS, Bernal B, Dunoyer C et al. Seizure disorders: Functional MR Imaging for Diagnostic Evaluation and Surgical Treatment Prospective Study. Radiology 2005; 236:247-253.
  11. Medina LS, Bernal B, Ruiz J. Role of functional MR in determining language dominance in epilepsy and nonepilepsy populations: a Bayesian analysis. Radiology 2007; 242(1): 94-100.
  12. National Imaging Associates Inc. Functional Brain MRI, 09/14.
  13. National Mental Health Information Center. Children’s Mental Health Facts, Children and Adolescents with Mental Emotional, and Behavioral Disorders, 04/03.
  14. Pantano P, Mainero C, Lenzi D. A longitudinal fMRI study on motor activity in patients with multiple sclerosis. Brain 2005; 128(9): 2146-2153.
  15. Pearlson G, Calhoun V. Structural and Functional Magnetic Resonance Imaging in Psychiatric Disorders 2007; 52: 158-166.
  16. Petrella JR, Shah LM, Harris KM et al. Preoperative Functional MR Imaging Localization of Language and Motor Areas: Effect on Therapeutic Decision Making in Patients with Potentially Resectable Brain Tumors. Radiology 2006; 240:793-802.
  17. Radiological Society of North America, Inc. (RSNA) Radiology Info™-Functional MR Imaging (fMRI)-Brain, 07/06/07.
  18. Ruff IM, Petrovich B, Brennan NM et al. Assessment of the language laterality index in patients with brain tumor using functional MR imaging: effects of thresholding, task selection, and prior to surgery. American Journal of Neuroradiology 2008; 29(3): 528-535.
  19. Sabsevitz DS, Swanson SJ, Hammeke TA et al. Use of preoperative functional neuroimaging to predict language deficits from epilepsy surgery. Neurology 2003; 60(11): 1788-1792.
  20. Sabsevitz DX, Swanson SJ, Hammeke TA et al. Use of Preoperative Functional Neuroimaging to Predict Language Deficits from Epilepsy Surgery. Neurology 2003; 60:1788-1792.
  21. Tharin S, Golby A. Functional brain mapping and its applications to neurosurgery. Operative Neurosurgery 2007; 60(4 Suppl 2): 185-201; discussion 201-218.
  22. Wu T, Hallet M. A. A functional MRI study of automatic movements in patients with Parkinson’s disease. Brain 2005; 128(10): 2250-2259.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/26/15.

GUIDELINE UPDATE INFORMATION:

08/15/07

New Medical Coverage Guideline.

01/21/08

Updated Program Exceptions.

05/15/08

Scheduled review. No change in position statements. Updated description section, and references.

05/15/09

Annual review. No change in position statements. Updated references.

05/21/09

Removed Federal Employee Plan (FEP) from BCBSF Radiology Management program exception statement. Added FEP program exception statement: FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

07/01/09

Updated BCBSF Radiology Management program exception; added BlueSelect.

01/01/10

Revised BCBSF Radiology Management program exception section.

05/15/11

Scheduled review; no change in position statement. Updated references.

01/01/13

Annual HCPCS coding update; revised 96020 code descriptor.

05/11/14

Revision: Program Exceptions section updated.

03/15/15

Annual review; revised position statement. Updated references.

Date Printed: October 20, 2017: 02:05 PM