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Date Printed: October 23, 2017: 07:32 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.

04-70540-17

Original Effective Date: 07/01/07

Reviewed: 12/03/15

Revised: 09/29/17

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Magnetic Resonance Imaging (MRI) Spine (Cervical, Thoracic, Lumbar)

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.

POSITION STATEMENT:

MRI of the spine (cervical, thoracic and lumbar) meets the definition of medical necessity for the following:

INDICATIONS FOR CERVICAL SPINE MRI:

For evaluation of known or suspected multiple sclerosis (MS)

For evaluation of neurologic deficits

For evaluation of chronic or degenerative changes (e.g., osteoarthritis, degenerative disc disease)

For evaluation of new onset of neck pain

For evaluation of trauma or acute injury within past 72 hours

Presents with radiculopathy, muscle weakness, abnormal reflexes, and/or sensory changes along a particular dermatome (nerve distribution)

For evaluation of known tumor, cancer, or evidence of metastasis

For evaluation of suspected tumor

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

For evaluation of known or suspected infection, abscess, or inflammatory disease

For evaluation of immune system suppression (e.g., HIV, chemotherapy, leukemia, lymphoma)

For preoperative evaluation [if surgery scheduled within the next thirty (30) days]

For post-operative/procedural evaluation for surgery or fracture occurring within the past six (6) months:

Other indications for a Cervical Spine MRI

Combination of Studies with Cervical Spine MRI:

Cervical MRI/CT

Brain MRI/Cervical MRI

INDICATIONS FOR THORACIC SPINE MRI:

For evaluation of neurologic deficits

For evaluation of chronic or degenerative changes (e.g., osteoarthritis, degenerative disc disease)

For evaluation of new onset of back pain

For evaluation of trauma or acute injury within past 72 hours

For evaluation of known tumor, cancer or evidence of metastasis

For evaluation of suspected tumor

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

For evaluation of known or suspected infection, abscess, or inflammatory disease

For evaluation of immune system suppression (e.g., HIV, chemotherapy, leukemia, or lymphoma)

For post-operative/procedural evaluation for surgery or fracture occurring within the past six (6) months:

Other indications for a Thoracic Spine MRI

Known or suspected Syrinx or syringomyelia.

Combination of Studies with Thoracic Spine MRI:

Cervical/Thoracic/Lumbar MRI:

INDICATIONS FOR LUMBAR SPINE MRI:

For evaluation of neurologic deficits

For evaluation of chronic or degenerative changes (e.g., osteoarthritis, degenerative disc disease)

For evaluation of new onset of back pain

For evaluation of trauma or acute injury within past 72 hours

For evaluation of known tumor, cancer or evidence of metastasis

For evaluation of suspected tumor

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

For evaluation of known or suspected infection, abscess, or inflammatory disease

For evaluation of immune system suppression (e.g., HIV, chemotherapy, leukemia, or lymphoma)

For post-operative/procedural evaluation for surgery or fracture occurring within the past six (6) months:

Other indications for a Lumbar Spine MRI

Combination of Studies with Lumbar Spine MRI:

Cervical/Thoracic/Lumbar MRI:

*Conservative therapy (spine) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections ( epidural, facet, bursal, and/or joint, not including trigger point), and diathermy can be utilized. Active modalities may consist of physical therapy, a physician supervised **home exercise program (HEP), and/or chiropractic care.

** A home exercise program (HEP) must consist of the following two elements:

1. Information on an exercise prescription/plan is provided to the member.

2. Follow up is conducted (after 4-6 weeks), regarding completion of HEP or inability to complete HEP due to a physical reason (e.g., increased pain, inability to physically perform exercises). NOTE: Member inconvenience or noncompliance without explanation does not constitute inability to complete a HEP.

BILLING/CODING INFORMATION:

CPT Coding:

72141

Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; without contrast material

72142

Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; with contrast material(s)

72146

Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without contrast material

72147

Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; with contrast material(s)

72148

Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material

72149

Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; with contrast material(s)

72156

Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical

72157

Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic

72158

Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar

HCPCS Coding:

S8042

Magnetic resonance imaging (MRI), low-field

REIMBURSEMENT INFORMATION:

Reimbursement for MRI imaging (72141-72158) of the same anatomical area is limited to one (1) MRI imaging within a 6-month period. MRI imaging (72141-72158) 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 of member who have had an operative, interventional or therapeutic procedure (e.g., surgery, embolization), reevaluation due to change in clinical status (e.g., deterioration), new or worsening clinical findings, (e.g., neurologic signs, symptoms), medical intervention which warrants reassessment, reevaluation for treatment planning, follow-up during and after completion of therapy or treatment to assess effectiveness, and evaluation after intervention or surgery.

Reimbursement for MRI imaging (72141-72158) 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 (72141-72158) within a 12-month period. MRI imaging (72141-72158) 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 spine (cervical, thoracic, lumbar).

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 Spine, (L29222) located at fcso.com.

DEFINITIONS:

Abscess: a localized collection of pus buried in tissues, organs, or confined spaces.

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).

Arthritis: inflammation of a joint. Acute arthritis: arthritis marked by pain, heat, redness, and swelling, due to inflammation, infection, or trauma. Chronic inflammatory arthritis: inflammation of joints in chronic disorders such as rheumatoid arthritis. Rheumatoid arthritis: a chronic systemic disease primarily of the joints, usually polyarticular, marked by inflammatory changes in the synovial membranes and articular structures and by muscle atrophy and rarefaction o the bones. In late stages deformity and ankylosis develop.

Cauda equine syndrome: dull aching pain of the perineum, bladder, and sacrum, generally radiating in a sciatic fashion, with associated paresthesias and areflexic parlysis, due to compression of the spinal nerve roots.

Discitis: inflammation of a disk, particularly of an interarticular disk.

Dysraphism: incomplete closure of a raphe (a seam; anatomic terminology for the line of union of the halves of any of various symmetrical parts); defective fusion, particularly of the neural tube.

Osteomyelitis: inflammation of bone caused by infection, usually by a pyogenic organism, although any infectious agent may be involved. It may remain localized or may spread through the bone to involve the marrow, cortex, cancellous tissue, and periosteum.

Spondylitis: inflammation of the vertebrae, also called rachitis.

Syringomyelia: a slowly progressive syndrome of cavitation in the central segments of the spinal cord, generally in the cervical region, but sometimes extending up into the medulla oblonga (syringobulbia) or down into the thoracic region; it may be of developmental origin, arise secondary to tumor, trauma, infarction, or hemorrhage, or be of unknown cause. It results in neurologic deficits, usually segmental muscular weakness and atrophy with a dissociated sensory loss (loss of pain and temperature sensation, with preservation of the sense of touch), and thoracic scoliosis is often present.

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

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) 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

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 Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Adult Spine, 2006.
  2. American College of Radiology ACR Appropriateness Criteria®: Ataxia 2012.
  3. American College of Radiology ACR Appropriateness Criteria®: Chronic Neck Pain 2010.
  4. American College of Radiology ACR Appropriateness Criteria®: Myelopathy 2011.
  5. American College of Radiology ACR Appropriateness Criteria®: Low Back Pain 2011.
  6. American College of Radiology ACR Appropriateness Criteria®: Suspected Spine Trauma 2012.
  7. Blue Cross Blue Association Positional Magnetic Resonance Imaging (MRI) (6.01.04), 04/14.
  8. National Imaging Associates, Inc. MRI Cervical Spine Clinical Guideline, 2017.
  9. National Imaging Associates, Inc. MRI Thoracic Spine Clinical Guideline, 2017.
  10. National Imaging Associates, Inc. MRI Lumbar Spine Clinical Guideline, 2017.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/03/15.

GUIDELINE UPDATE INFORMATION:

07/01/07

New Medical Coverage Guideline.

01/21/08

Updated the Program Exceptions.

07/15/08

Scheduled reviewed. 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.

07/15/10

Annual review: format changes, added indications for bone marrow MRI, added program exception for Medicare Advantage products, and updated references.

10/01/11

Revision; formatting changes.

10/15/12

Scheduled review; Deleted Fonar Stand-Up MRI system. Deleted current position statements for MRI of the spine (cervical, thoracic, lumbar). Update position statements for spine (cervical, thoracic, lumbar). Added criteria for imaging which exceed limit. Added statement for re-imaging or additional imaging. Added Medicare Advantage program exception (nationally non-covered indications); MRI of cortical bone and calcifications and procedures involving spatial resolution of bone and calcifications are not considered reasonable and necessary indications. Deleted Medicare Advantage products ICD-9 codes. Updated references.

01/01/14

Review/revision. Added abnormal (reflexes) or new onset of abnormal sensory changes along a particular dermatome (nerve distribution) as documented on physical examination: for evaluation of neurologic deficits. Added muscle weakness and abnormal reflexes for pain (chronic neck, chronic back): for evaluation of chronic or degenerative changes (e.g., osteoarthritis, degenerative disc disease). Added as evidenced by signs/symptoms, laboratory or prior imaging findings. Updated program exception: for evaluation of immune system suppression. Updated program exception and references.

01/01/15

Scheduled review; maintain position statement. Deleted “and when ordered by a neurosurgeon, orthopedist or surgeon” (cervical spine section; for preoperative evaluation). Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period. Updated references.

12/15/15

Revised indications: MRI of the spine (cervical, thoracic and lumbar). Added indications for: post-operative/procedural evaluation and combination studies. Updated references.

09/29/17

Added information related to conservative therapy. Updated references.

Date Printed: October 23, 2017: 07:32 AM