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Date Printed: June 23, 2017: 11:44 AM

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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.

04-70540-11

Original Effective Date: 07/01/07

Reviewed: 12/04/14

Revised: 01/01/15

Subject: Magnetic Resonance Imaging (MRI) Brain and Head

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    
           

DESCRIPTION:

Magnetic resonance imaging (MRI) is a radiation-free, noninvasive, technique used to produce high quality sectional images of the inside of the body in multiple planes. MRI uses natural magnetic properties of the hydrogen atoms in the body that emit radiofrequency signals when exposed to radio waves within a strong magnetic field. These signals are processed and converted by a computer into high-resolution, three-dimensional, tomographic images. Images and resolution produced by MRI is quite detailed. For some MRI, contrast materials (e.g., gadolinium, gadoteridol, non-ionic and low osmolar contrast media, ionic and high osmolar contrast media) are used to enable visualization of a body system or body structure.

The U.S. Food and Drug Administration’s (FDA) cleared MRI systems for marketing through the 510(k) process. The Fonar Stand-Up MRI system received FDA marketing clearance in October 2000.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the magnetic resonance imaging (MRI) of the brain/head and imaging results (e.g., images, clinical reports) should be maintained in the member’s medical record. Documentation may be requested as part of the review process.

Magnetic Resonance Imaging (MRI) of the brain or head meets the definition of medical necessity for the following:

Aneurysm or Arteriovenous Malformation (AVM) (known or suspected)

Brain Tumor/Metastasis (known or suspected)

Congenital Abnormality (e.g., hydrocephalus, craniosynostosis) (known or suspected)

Evaluation of Neurological Deficits

Headache (Evaluation)

Inflammatory Disease or Infection (known or suspected)

Multiple Sclerosis (MS) (known or suspected)

Parkinson’s disease

Seizure Disorder (known or suspected)

Stroke (known or suspected)

Trauma (known or suspected)

Tumor or Rule Out Metastasis

Other

BILLING/CODING INFORMATION:

The following codes may be used to describe magnetic resonance imaging of the brain.

CPT Coding:

70551

Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material

70552

Magnetic resonance (e.g., proton) imaging, brain (including brain stem); with contrast material(s)

70553

Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences

HCPCS Coding:

S8042

Magnetic resonance imaging (MRI), low-field

REIMBURSEMENT INFORMATION:

Reimbursement for MRI imaging (70551-70553) performed on the same anatomical area is limited to one (1) MRI imaging (70551-70553) within a 6-month period. MRI imaging in excess of one (1) within a 6-month period is subject to medical review for medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Reimbursement for MRI imaging (70551-70553) for an oncologic condition undergoing active treatment or active treatment completed within the previous 12 months on the same anatomical area is limited to four (4) MRI imaging (70551-70553) within a 12-month period. MRI imaging (70551-70553) for an oncologic condition in excess of four (4) within a 12-month period are subject to medical review of documentation to support medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Re-imaging or additional imaging of the brain or head due to poor contrast enhanced exam or technically limited exam is the responsibility of the imaging provider.

Open MRI Units (Stand-Up MRI, Sitting MRI and Positional MRI)

Open MRI units of any configuration, including MRI units that allow imaging when standing (Stand-up MRI) or when sitting (Sitting MRI), are considered to be an acceptable standard alternative to standard “closed” MRI units. Stand-up MRI and sitting MRI may be reported like a standard MRI. No additional payment will be made for stand-up MRI or sitting MRI.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for magnetic resonance imaging (MRI) brain and head.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology reason for study

18785-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study-date and time

18779-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study observation

18834-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-study observation

18782-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-impression

19005-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology study-recommendation (narrative)

18783-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

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 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:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Magnetic Resonance Imaging of the Brain, (L29220) located at fcso.com.

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Magnetic Resonance Imaging (MRI), (220.2) located at cms.gov.

DEFINITIONS:

Acoustic neuroma: a progressively enlarging, benign tumor, usually within the internal auditory canal arising from Schwann cells of the vestibular division of the eighth cranial nerve; the symptoms, which vary with the size and location of the tumor, may include hearing loss, headache, disturbances of balance and gait, facial numbness or pain, and tinnitus. It may be unilateral or bilateral (neurofibromatosis).

Arnold Chiari malformation: herniation of the cerebellar tonsils and vermis through the foramen magnum into the spinal canal. It is always associated with lumbosacral myelomeningocele, and hydrocephalus and mental defects are common (also called Arnold-Chaiari deformity or syndrome).

Encephalopathy: any degenerative disease of the brain.

Galactorrhea: productions of breast milk in men or in women who are not breast feeding.

Nystagmus: an involuntary, rapid, rhythmic movement of the eyeball, which may be horizontal, vertical, rotatory, or mixed.

Syringomyelia: a rare disorder that causes a cyst (syrinx) to form in the spinal cord.

Syrinx: an abnormal cavity in the spinal cord in syringomyelia.

RELATED GUIDELINES:

Functional MRI, 04-70540-10

Magnetic Resonance Spectroscopy (MRS), 04-70540-07
Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck, 04-70540-12

Magnetic Resonance Imaging (MRI) Chest & Cardiac, 04-70540-13

Magnetic Resonance Imaging (MRI) Abdomen and Pelvis, 04-70540-14

Magnetic Resonance Imaging (MRI) Upper Extremity, 04-70540-15

Magnetic Resonance Imaging (MRI) Lower Extremity, 04-70540-16

Magnetic Resonance Imaging (MRI) Spine (Cervical, Thoracic, Lumbar), 04-70540-17

Magnetic Resonance Imaging (MRI) of the Breast, 04-70540-09

OTHER:

Other names used to report MRI:

Nuclear Magnetic Resonance (NMR)
Open MRI

Other names used to report Positional MRI:

Position MRI (pMRI)
Sitting MRI
Stand-Up MRI
Standing MRI
Weight-bearing MRI

REFERENCES:

1. American College of Radiology (ACR). Appropriateness Criteria® Headache, 2013.

2. American College of Radiology (ACR). Appropriateness Criteria® Vertigo and Hearing Loss, 2013.

3. ACR–ASNR–SPR Practice Parameter for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Brain, 2014.

4. Blue Cross Blue Association Positional Magnetic Resonance Imaging (MRI) Medical Policy 6.01.48, 04/14.

5. Centers for Medicare & Medicaid Service NCD for Magnetic Resonance Imaging (220.2), 09/06/11.

6. First Coast Service Options, Inc. Local Coverage Determination for Magnetic Resonance Imaging of the Brain, (L29220), 07/07/11.

7. Kang M, Escott E. Imaging of tinnitus. Otolaryngologic Clinics of North America 2008; 41(1):179-193,

8. Medicare National Coverage Determinations Manual-Magnetic Resonance Imaging, 09/28/09.

9. National Imaging Associates, Inc. MRI Brain (includes internal auditory canal) Clinical Guidelines, 07/13.

10. Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000; 216(2): 342-349.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/04/14.

GUIDELINE UPDATE INFORMATION:

07/01/07

New Medical Coverage Guideline.

01/21/08

Updated Program Exceptions.

07/15/08

Scheduled review. No change in position statement. Added functional MRI to related guideline section. Updated references and related Internet links.

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

Annual HCPCS coding update: deleted 70557, 70558, and 70559. Revised BCBSF Radiology Management program exception section.

03/15/10

Updated indications. Add program exception for Medicare Advantage products. Updated references.

07/15/10

Code update; deleted 77084.

10/01/11

Revision; formatting changes.

04/15/12

Scheduled review. Revised, deleted and added position statement: Revised aneurysm or AVM, congenital abnormality, headache inflammatory disease or infection, multiple sclerosis, stroke, trauma, tumor or rule out metastasis and other section. Deleted but is not limited to, CNS signs or symptoms and tumor or rule out metastasis. Deleted Medicare Advantage product ICD-9 diagnosis codes. Added brain tumor/metastasis, evaluation of neurological deficits, Parkinson’s disease and post-operative evaluation. Updated references.

11/15/13

Scheduled review; deleted screening for aneurysm in polycystic kidney disease, Ehlers Danlos syndrome, fibromuscular dysplasia or aortic coarctation, tumor or rule out metastasis; added pre-operative evaluation, suspected acoustic neuroma (Schwannoma) or cerebellar pontine angle tumor with any of the following signs and symptoms: unilateral hearing loss by audiometry, headache, disturbed balance or gait, tinnitus, facial weakness, altered sense of taste, suspected glomus tumor, and acute onset or asymmetrical sensory neurological hearing loss. Updated definitions, program exceptions and reference sections.

05/15/14

Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period.

01/01/15

Scheduled review; maintain positon statement. Updated references.

Date Printed: June 23, 2017: 11:44 AM