Print

Date Printed: May 24, 2018: 11:41 AM

Private Property of Blue Cross and Blue Shield of Florida.
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: 01/25/18

Revised: 02/15/18

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 the following:

Orbit

  • Evaluation of decrease range of motion of eyes.
  • Screening and assessment of suspected hyperthyroidism (e.g., Graves disease).
  • Screening and assessment of known or suspected optic neuritis (assessment)
  • Progressive vision loss.
  • Assessment of proptosis (exophthalmos).
  • Suspected orbital pseudotumor.
  • Assessment of trauma
  • Screening and evaluation of an ocular tumor (e.g., melanoma).
  • Orbital infection.
  • Evaluation of unilateral visual deficit.
  • A follow-up study may be needed to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Combination of Studies with Orbit MRI

Brain MRI/Orbit MRI

For approved indications as noted above and being performed in a child under 3 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial tumor e.g., trilateral retinoblastoma).

Unilateral papilledema: to distinguish a compressive lesion on the optic nerve or optic disc swelling associated with acute demyelinating optic neuritis in multiple sclerosis from nonarteritic anterior ischemic optic neuropathy (NAION), central retinal vein occlusion or optic nerve infiltrative disorders.

Additional Information Related to Orbit MRI

MRI and Optic Neuritis: MRI is useful in the evaluation of patients who have signs and symptoms of optic neuritis. These signs and symptoms may be the first indications of demyelinating disease, e.g., multiple sclerosis (MS). MRI findings showing the presence of three or more bright spots in brain white matter on T2-weighted images are indicative of MS and may be used as a criterion for initiating treatment.

MRI and Exophthalmos (Proptosis): Proptosis is characterized by a bulging of one or two eyes and may be caused by hyperthyroidism (Graves’ disease) or it may be caused by other conditions, e.g., orbital tumors, infection and inflammation. The degree of exophthalmos in thyroid-associated opthalmopathy is related to the orbital fatty tissue volume. MRI is able to define orbital soft tissues and measure the volumetric change in orbital fatty tissues.

MRI and Orbit Tumors: The most common intraocular malignant tumor is choroidal melanoma. Most choroidal melanomas can be evaluated by ophthalmoscopy and ultransonography. MRI may be used to differentiate the types of mass lesions and to define their extent.

Retinoblastoma and intracranial tumors: Histologically similar tumors may occur in the pineal, suprasellar or parasellar regions of patients with ocular retinoblastoma, also known as “trilateral retinoblastoma”. The incidence of these intracranial tumors in either unilateral or bilateral retinoblastoma patients is 1.5%-5 %.

Unilateral papilledema: The most common causes of unilateral optic disc edema are nonarteritic anterior ischemic optic neuropathy (NAION), optic neuritis (termed papillitis when disc swelling is present), and orbital compressive lesions. Idiopathic intracranial hypertension (pseudotumor cerebri) and central retinal vein occlusive lesions can also present with unilateral papilledema.

Nonarteritic anterior ischemic optic neuropathy (NAION): Nonarteritic anterior ischemic optic neuropathy (NAION) is the most common form of ischemic optic neuropathy. It is an idiopathic, ischemic insult of the optic nerve head characterized by acute, monocular, painless visual loss with optic disc swelling. The pathophysiology for reduction in blood flow to the optic nerve is controversial.

Face

  • Evaluation of sinonasal or facial tumor.
  • Assessment of osteomyelitis.
  • Diagnosis of parotid or other salivary stones.
  • Assessment of trauma (e.g., suspected facial bone fractures).
  • Diagnosis of facial abscesses.
  • A follow-up study may be needed to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Additional Information Related to Face MRI

Facial Bone Fractures: MRI of the facial bones following trauma provides high quality images of fracture sites and adjacent soft tissue injury. It is helpful in planning surgical intervention, if needed

Sinonasal and Facial Tumors: MRI of the face produces images depicting a patient’s paranasal sinus cavities, hollow and air-filled spaces located within the bones of the face and surrounding the nasal cavity. Face MRI of this system of air channels connecting the nose with the back of the throat may be used to evaluate suspected nasopharyngeal tumors. Face MRI may detect other tumors and usually provide information about the tumor invasion into surrounding bony structures.

Chronic Osteomyelitis: MRI may be used in patients with chronic osteomyelitis to evaluate bone involvement and to identify soft tissue involvement (cellulitis, abscess and sinus tracts). It is used to detect intramedullary and soft tissue gas, sequestra, sinus tracts, and foreign bodies but is not sufficient for the assessment of the activity of the process.

Parotid and Other Salivary Stones: The sensitivity of MRI to minimal amounts of calcific salts makes it well suited for the imaging of small, semicalcified salivary stones. Early diagnosis and intervention are important because patients with salivary stones often develop sialadenitis. With early intervention, it may be possible to avoid further gland degeneration and salivary gland removal. The MRI identifies the exact location of a salivary stone, expediting removal.

Neck

Evaluation of known tumor, cancer or mass

  • Evaluation of neck tumor, mass or history of cancer in patient with suspected recurrence or metastasis [based on symptoms or examination findings (may include new or changing lymph nodes)].
  • Evaluation of skull base tumor, mass or cancer.
  • Evaluation of tumors of the tongue, larynx, nasopharynx pharynx, or salivary glands.
  • 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 planned.

Indication for combination studies for the initial pre-therapy staging of cancer, or ongoing tumor/cancer surveillance or evaluation of suspected metastases

  • ≤ 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine or Lumbar Spine.
  • Cancer surveillance – Active monitoring for recurrence as clinically indicated.

Evaluation of suspected tumor, cancer or mass

  • Initial evaluation of suspicious mass/tumor found on an imaging study and needing clarification or found by physical exam and remains non-diagnostic after x-ray or ultrasound is completed.
  • Evaluation of palpable suspicious lesions in mouth or throat.
  • Evaluation of non-thyroid masses in the neck when persistent, greater than one month, and >/= to 1 cm or associated with generalized lymphadenopathy.

Evaluation of known or suspected inflammatory disease or infection

  • Evaluation of lymphadenopathy in the neck when greater than one month, and >/= to 1 cm or associated with generalized lymphadenopathy.
  • Pre-operative evaluation.
  • Post-operative/procedural evaluation (e.g., post neck dissection/exploration)
  • A follow-up study may be needed for evaluation of a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that indicates why additional imaging is needed for the type and area(s) requested.

Other indications for a Neck MRI

  • For evaluation of vocal cord lesions or vocal cord paralysis.
  • For evaluation of stones of the salivary glands and ducts.
  • Brachial plexus dysfunction (Brachial plexopathy/Thoracic Outlet Syndrome).

Indications for combination studies

Abdomen CT/Pelvis CT/Chest CT/Neck MRI/Neck CT with MUGA: Known tumor/cancer for initial staging or evaluation before starting chemotherapy or radiation treatment.

Additional Information Related to Neck MRI:

MRI and Brachial Plexus: MRI is the only diagnostic tool that accurately provides high resolution imaging of the brachial plexus. The brachial plexus is formed by the cervical ventral rami of the lower cervical and upper thoracic nerves which arise from the cervical spinal cord, exit the bony confines of the cervical spine, and traverse the soft tissues of the neck, upper chest, and course into the arms.

MRI and Neck Tumors: MRI plays a significant role in the therapeutic management of neck tumors, both benign and malignant. It is the method of choice for therapy planning as well as follow-up of neck tumors. Frequently for skull base tumors, CT is preferred, but MRI provides valuable information to support diagnosis of the disease.

MRI and Vocal Cord Paralysis or Tumors: MRI helps in the discovery of tumors or in estimating the depth of invasion of a malignant process. It provides a visualization of pathological changes beneath the surface of the larynx. MRI scans may indicate the presence or absence of palsy and possible reasons for it. If one or both vocal cords show no movement during phonation, palsy may be assumed.

MRI and Cervical Lymphadenopathy: MRI can show a conglomerate nodal mass that was thought to be a solitary node. It can also help to visualize central nodal necrosis and identify nodes containing metastatic disease. Imaging of the neck is not done just to evaluate lymphadenopathy, but is performed to evaluate a swollen lymph node and an unknown primary tumor site. Sometimes it is necessary to require a second imaging study using another imaging modality (e.g., a CT study to provide additional information).

MRI and Salivary Stones: Early diagnosis and intervention are important because patients with salivary stones may eventually develop sialadenitis. MRI provides excellent image contrast and resolution of the salivary glands and ducts and helps in the evaluation of stones.

Temporomandibular Joint (TMJ)

  • Evaluation of dysfunctional temporomandibular joint unsuccessful conservative therapy for at least four (4) weeks with bite block or TMJ splint and anti-inflammatory medication.
  • Evaluation of frozen or locked jaw.
  • Preoperative evaluation of dysfunctional TMJ in members for orthognathic surgery.
  • Persistent temporomandibular joint dysfunction (e.g., difficulty in opening mouth, pain with chewing) after surgical repair.
  • A follow-up study may be needed to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Additional Information Related to Temporomandibular Joint (TMJ) MRI

MRI Imaging of Temporomandibular Joint – Imaging of the temporomandibular joint has been difficult as the mandibular condyle is small and located close to dense and complex anatomic structures. MRI produces cross-sectional multiplanar images that document both soft and osseous tissue abnormalities of the joint and the surrounding structures and may help in determining the pathology around the joint.

Sinus

  • Evidence of sinonasal or skull base tumor on physical exam, plain sinus x-ray or previous CT
  • Cerebrospinal fluid (CSF) leak.
  • Unresolved sinusitis after four (4) consecutive weeks of medication (e.g., antibiotics, steroids, antihistimines), when sinus CT is insufficient, when there is a suspected mass lesion causing the disease, when there is suspected invasive fungal sinusitis, or severe complications are suspected (such as orbital or intracranial complications).
  • Osteomyelitis (rare) of the facial bone.
  • A follow-up study may be needed to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Additional Information Related to Sinus MRI

Sinusitis: In addition to CT scanning, magnetic resonance (MR) imaging of the sinuses, orbits, and brain may be performed if there are extensive or severe complications of sinusitis suspected.

Limitations of Sinus MRI: MRI has limitations in the definition of the bony anatomy, but is sensitive for differentiating between inflammatory disease and malignant tumors.

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, (L34375) 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.

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, 03/17.
  3. National Imaging Associates, Inc. Clinical Guideline, MRI Orbit, 2018.
  4. National Imaging Associates, Inc. Clinical Guideline, MRI Neck, 2018.
  5. National Imaging Associates, Inc. Clinical Guideline, MRI Temporomandibular Joint (TMJ), 2018.
  6. National Imaging Associates, Inc. Clinical Guideline, MRI Face, 2018.
  7. National Imaging Associates, Inc. Clinical Guideline, MRI Sinus, 2018.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 01/25/18.

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.

02/15/18

Revision; updated and revised position statement (orbit, face, neck, TMJ, sinus). Updated program exceptions and references.

Date Printed: May 24, 2018: 11:41 AM