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Date Printed: August 23, 2017: 06:06 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.

04-70540-12

Original Effective Date: 07/01/07

Reviewed: 04/28/16

Revised: 05/15/16

Subject: Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck

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:

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:

Magnetic Resonance Imaging (MRI) meets the definition of medical necessity for evaluation of the following:

Orbit

Face

Neck

Temporomandibular Joint (TMJ)

Sinus

MRI Field Strength

MRI field strength, including intermediate and low field strength MRI units are considered an acceptable alternative to standard closed MRI units.

MRI imaging, when used as a screening tool in the absence of signs or symptoms of a disease or condition, without a diagnosis, or specific clinical indication does not meet the definition of medical necessity as there is insufficient clinical evidence to support the use of MRI imaging as a screening tool.

BILLING/CODING INFORMATION:

CPT Coding:

70336

Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s)

70540

Magnetic resonance (e.g., proton) imaging orbit, face and neck; without contrast material(s)

70542

Magnetic resonance (e.g., proton) imaging orbit, face and neck; with contrast material(s)

70543

Magnetic resonance (e.g., proton) imaging orbit, face and neck; without contrast material(s), followed by contrast material(s) and further sequences

HCPCS Coding:

S8042

Magnetic resonance imaging (MRI), low-field

REIMBURSEMENT INFORMATION:

Reimbursement for MRI imaging (70336, 70540-70543) performed on the same anatomical area is limited to one (1) MRI imaging (70336, 70540-70543) 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.

Additional MRI imaging of the same anatomical area may be appropriate for the following, including, but not limited to: diagnosis, staging or follow-up of cancer, follow-up assessment during or after therapy for known metastases, follow-up or evaluation after treatment, procedure, intervention or surgery, reevaluation due to change in clinical status, new or worsening clinical findings, medical intervention which warrants reassessment, reevaluation for treatment planning, and follow-up during and after completion of therapy or treatment to assess effectiveness.

Reimbursement for MRI imaging (70336, 70540-70543) 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 (70336, 70540-70543) within a 12-month period. MRI imaging (70336, 70540-70543) 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 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-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) orbit, face, temporomandibular joint (TMJ) and neck.

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 Orbit, Face, and Neck, (L29221) located at fcso.com.

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

DEFINITIONS:

Hyperthyroidism: a condition caused by excessive production of iodinated thyroid hormones; characteristics include goiter, tachycardia or atrial fibrillation, widened pulse pressure, palpitations, fatigability, nervousness and tremor, heat intolerance and excessive sweating, warm, smooth, moist skin, weight loss, muscular weakness, excessive defecation, emotional liability, and ocular signs such as stare, slowing of eyelid movements, photophobia, and sometimes exophthalmos.

Lymphadenopathy: disease of the lymph nodes.

Nystagmus: Involuntary usually rapid movement of the eyeballs (as from side to side) occurring normally with dizziness during and after bodily rotation or abnormally following head injury or as a symptom of disease.

Proptosis: Abnormal protrusion of the eyeball.

RELATED GUIDELINES:

Magnetic Resonance Spectroscopy (MRS), 04-70540-07
Magnetic Resonance Imaging (MRI) of the Breast, 04-70540-09

Magnetic Resonance Imaging (MRI) Brain and Head, 04-70540-11

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

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. ACR-ASNR-SPR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Head and Neck, 2012.
  2. Blue Cross Blue Association Positional Magnetic Resonance Imaging (MRI) 6.01.18, 9/15.
  3. Centers for Medicare & Medicaid Services NCD for Magnetic Resonance Imaging (220.2), 2010
  4. First Coast Service Options, Inc. Local Coverage Determination for Magnetic Resonance Imaging of the Orbit, Face, and/ or Neck, L34375, 10/01/15.
  5. National Imaging Associates, Inc. Clinical Guideline, MRI Orbit, 2016.
  6. National Imaging Associates, Inc. Clinical Guideline, MRI Neck, 2016.
  7. National Imaging Associates, Inc. Clinical Guideline, MRI Temporomandibular Joint (TMJ), 2016.
  8. National Imaging Associates, Inc. Clinical Guideline, MRI Face, 2016.
  9. National Imaging Associates, Inc. Clinical Guideline, MRI Sinus, 2016.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/28/16.

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. 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

Revised BCBSF Radiology Management program exception section.

06/15/10

Annual review. Reformatted and updated position statement. Added program exception for Medicare Advantage products; covered indications and ICD-9 codes that support medical necessity. Updated references.

07/15/10

Code update; deleted 77084.

10/15/10

Revision related 2010 ICD-9 code added; added 784.92 to Medicare Advantage products program exception. Updated references.

10/01/11

Revision; formatting changes.

06/15/12

Scheduled review; added “orbital” Pseudotumor, unilateral visual deficit: orbit, tumors (parotid): face, “neck” lymphadenopathy: neck, “tumors” skull base: neck, e.g., failed conservative therapy: TMJ, “or locked” for frozen jaw: TMJ, “dysfunctional” for pre-operative evaluation of TMJ: TMJ, indications for sinus, criteria for imaging which exceed limit, statement for re-imaging or additional imaging, and definition for nystagmus and proptosis. Deleted “stones” (parotid): face, “mass” skull base: neck, and Medicare ICD-9 codes. Updated references.

01/01/14

Annual review. Revision; eye trauma (deleted to the eye; added assessment); added neck tumor, mass or with suspected recurrence or metastasis (based on symptoms or examination findings (may include new or changing lymph nodes); when persistent, greater than one month, and >/= to 1cm to non-thyroid mass in neck and evaluation of parathyroid tumor when: Ca > normal [>10.6 mg/dL] and PTH > normal [55 pg/mL]; with previous non-diagnostic ultrasound or nuclear medicine scan; and surgery is planned; neck lymphadenopathy (added when greater than one month, noted to be >/= to 1 cm or associated with generalized lymphadenopathy); skull bass (added mass or cancer); sinus (add “previous” to CT and deleted MRI. Deleted; neck tumors or malignancy (known or suspected): diagnosis or staging, evaluation or response to treatment and preoperative evaluation. Updated program exception.

01/01/15

Scheduled review; added cancer (known or suspected) and parotid and submandibular glands and ducts stones to position statement (neck section), pre-operative and post-operative/procedural evaluation (neck section), and “for orthognathic surgery” to preoperative evaluation of dysfunctional TMJ (temporomandibular joint (TMJ) section). Revised failed conservative therapy; add for at least four (4) weeks (temporomandibular joint (TMJ) section). Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period. Updated references.

05/15/16

Revisions; Deleted sinusitis (rhinosinusitis) unresponsive to 3 documented courses of 4 weeks of medical management (each documented course of treatment must be 4 weeks long) (e.g., antibiotics, nasal steroids, decongestants, anti-histamines). Added unresolved sinusitis after four (4) consecutive weeks of medication (e.g., antibiotics, steroids, antihistamines). Updated references.

Date Printed: August 23, 2017: 06:06 AM