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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.

04-70540-07

Original Effective Date: 08/15/01

Reviewed: 12/04/14

Revised: 01/01/15

Subject: Magnetic Resonance Spectroscopy (MRS)

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 Updates    
           

DESCRIPTION:

Magnetic resonance spectroscopy (MRS) is a noninvasive technique that can be used to measure the concentrations of different chemical components within tissues. The technique is based on the same physical principles as magnetic resonance imaging (MRI) and the detection of energy exchange between external magnetic fields and specific nuclei within atoms. The information produced by MRS is displayed graphically as a spectrum with peaks consistent with the various chemicals detected. MRS may be performed as an adjunct to MRI. An MRI image is first generated, and then MRS spectra are developed at the site of interest, termed the voxel. While an MRI provides an anatomic image of the brain, MRS provides a functional image related to underlying dynamic physiology. The information produced by MRS is used to assist in planning a course of treatment. MRS can be performed with existing MRI equipment, modified with additional software and hardware. Multiple software packages for performing proton MRS have received clearance by the U.S. Food and Drug Administration (FDA) through the 510(k) process.

POSITION STATEMENT:

Magnetic resonance spectroscopy (MRS) meets the definition of medical necessity when used to:

Magnetic resonance spectroscopy (MRS) is considered experimental or investigational, as there is insufficient clinical evidence data regarding the clinical utility to support the use of MRS for all other indications, and specifically for the following conditions:

BILLING/CODING INFORMATION:

CPT Coding:

76390

Magnetic resonance spectroscopy

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

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

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 the 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 Local Coverage Determination (LCD) was found at the time of the last guideline reviewed date. The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Magnetic Resonance Spectroscopy (MRS), (220.2.1) located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report magnetic resonance spectroscopy:

Magnetic resonance spectroscopy imaging (MRSI)
NMR (nuclear magnetic resonance) spectroscopy
Proton magnetic resonance spectroscopy (1H-MRS)
Proton spectroscopy

REFERENCES:

  1. Accuracy: An Evaluation of Intracranial Mass Lesions Characterized by Stereotactic Biopsy Findings. American Journal of Neuroradiology 2000; 21: 84-93.
  2. Agency for Healthcare Research and Quality-Magnetic Resonance Spectroscopy for Brain Tumors, 04/24/03.
  3. American College of Radiology, Maryland Carrier Advisory Committee, Section II. Proton Magnetic Resonance Spectroscopy, 06/12/96.
  4. ACR-ASNR-SPR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Spectroscopy of the Central Nervous System. Amended 2014.
  5. Astrakas LG, Zurakowowski D, Tzika AA et al. Noninvasive Magnetic Resonance Spectroscopic Imaging Biomarkers to Predict the Clinical Grade of Pediatric Brain Tumors. Clinical Cancer Research 2004; 10: 8220-8228.
  6. Bellmann-Strobl J, Stiepani H, Wuerfel J et al. MR spectroscopy (MRS) and magnetisation transfer imaging (MTI), lesion and clinical scores in early relapsing remitting multiple sclerosis: a combined cross-sectional and longitudinal study. European Radiology 2009; 19(8): 2066-2074.
  7. Blue Cross Blue Shield Association Medical Policy – Magnetic Resonance Spectroscopy 6.01.24, 12/13.
  8. Blue Cross Blue Shield Association Technology Assessment-Magnetic Resonance Spectroscopy for Evaluation of Suspected Brain Tumor, Vol. 8, No. 1, 06/03.
  9. Burtscher IM, Skagerberg G, Geijer B et al. Proton MR Spectroscopy and Preoperative Diagnostic.
  10. Centers for Medicare & Medicaid (CMS), NCD for Magnetic Resonance Spectroscopy (MRS), 220.2.1, 09/04.
  11. Dhermain FG, Hau P, LanfemannH et al. Advanced MRI and PET imaging assessment of treatment response in patients with gliomas. Lancet Neurology 2010; 9(9): 906-920.
  12. De Stefano N, Filippi M et al. Guidelines for using proton MR spectroscopy in multicenter clinical MS studies.  Neurology 2007; 69(20):1942-1952.
  13. Evelhoch J, Garwood M, Vigneron D et al. Expanding the Use of Magnetic Resonance in the Assessment of Tumor Response to Therapy: Workshop Report. Cancer Research 2005 August; 65 (16), 7041-7044.
  14. Floeth FW, Pauleit D, Wittsack HJ et. al. Multimodal Metabolic Imaging of Cerebral Gliomas: Positron Emission Tomography with [F] fluoroethyl-L-tyrosine and Magnetic Resonance Spectroscopy. Journal of Neurosurgery. 2005; 102: 318-327.
  15. Harry VN, Semple SI, Parkin DE et al. Use of new imaging techniques to predict tumour response to therapy. Lancet Oncology 2010; 11(1): 92-102. Hayes, Inc. Proton Magnetic Resonance Spectroscopy for Diagnosis of Brain Tumors. Lansdale, PA: HAYES, Inc., 2008.
  16. Hourani R, Brant LJ, Rizk T et al. Can Proton MR Spectroscopic and Perfusion Imaging Differentiate Between Neoplastic and Nonneoplastic Brain Lesions in Adults? American Journal of Neuroradiology 2008; 29: 366-372.
  17. Katz-Brull R, Lavin PT, Lenkinski RE. Clinical Utility of Proton Magnetic Resonance Spectroscopy in Characterizing Breast Lesions. Journal of the National Cancer Institute 2002; 94(16): 1197-1203.
  18. Kou Z, Wu Z, Tong KA et al. The role of advanced MR imaging findings as biomarkers of traumatic brain injury. Journal of Head Trauma Rehabilitation 2010; 25(4): 267-282.
  19. Krieger MD, Bluml S, McComb G. Magnetic resonance spectroscopy of atypical diffuse pontine masses. Neurosurgical Focus 2003; 15(1): 1-4.
  20. Kurhanewicz J, Bok R, Nelson S J, Vigneron DB. Current and potential applications of clinical 13C MR Spectroscopy. The Journal of Nuclear Medicine 2008; 49(3): 341-344.
  21. Law M, Cha S, Knopp EA et al. High-Grade Gliomas and Solitary Metastases: Differentiation by Using Perfusion and Proton Spectroscopic MR Imaging. Radiology 2002; 222: 715-721.
  22. Law M, Yang S, Wang H et al. Glioma Grading: Sensitivity, Specificity, and Predictive Values of Perfusion MR Imaging and Proton MR Spectroscopic Imaging Compared with Conventional MR Imaging. American Journal of Neuroradiology 2003; 14: 1989-1998.
  23. Lee SS, Park SH Kim HJ et al. Non-invasive assessment of hepatic steatosis: prospective comparison of the accuracy of imaging examinations. Journal of Hepatology 2010; 52(4): 579-585.
  24. Majos C, Alonso J, Aguilera C, et al. Utility of Proton MR Spectroscopy in the Diagnosis of Radiologically Atypical Intracranial Meningiomas. Neuroradiology 2003; 45: 129-36.
  25. Martomez-Bisbal MC, Celda B. Proton magnetic resonance spectroscopy imaging in the study of human brain cancer. Quarterly Journal of Nuclear Medicine and Molecular Imaging 2009; 53(6): 618-630.
  26. Medicare National Coverage Determinations Manual Chapter 1, Part 4 (Sections 200-310.1) Coverage Determinations-Magnetic Resonance Spectroscopy 220.2.1, 09/10/04.
  27. Meyerand ME, Pipas JM, Mamourian A et al. Classification of Biopsy-Confirmed Brain Tumors Using Single-Voxel MR Spectroscopy. American Journal Neuroradiology 1999; 20:117-123.
  28. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Central Nervous System Cancers Version 2.2014.
  29. National Imaging Associates, Inc. Clinical Guideline MR Spectroscopy, 07/13.
  30. Nelson SJ. Multivoxel Magnetic Resonance Spectroscopy of Brain Tumors. Molecular Cancer Therapeutics. 2003; 2:497-507.
  31. Rossi A, Gandolfo C, Morana G et al. New MR sequences (diffusion, perfusion, spectroscopy) in brain tumours. Pediatric Radiology 2010; 40(6): 999-1009.
  32. Sciarra A, Panebianco V, Ciccariello M et al. Value of magnetic resonance spectroscopy imaging and dynamic contrast-enhanced imaging for imaging for detecting prostate cancer foci in men with prior negative biopsy. Clinical Cancer Research 2010; 16(6): 1875-1883.
  33. Soares DP, Law M. Magnetic resonance spectroscopy of the brain: review of metabolites and clinical applications. Clinical Radiology 2009; 64(1): 12-21.
  34. Sood S, Gupta T, Tsiouris AJ. Advanced magnetic resonance techniques in neuroimaging: diffusion, spectroscopy, and perfusion. Seminars in Roentgenology 2010; 45(2): 137-146.
  35. Sundgren PC. MR spectroscopy in radiation injury. American Journal of Neuroradiology 2009; 30(8): 1469-1476.
  36. Taouli B, Ehman RL, Reeder SB. Advanced MRI methods for assessment of chronic liver disease. American Journal of Roentgenology 2009; 193(1): 14-27.
  37. U.S. Food and Drug Administration Center for Devices and Radiological Health (CDRH)-Magnetic Resonance Diagnostic Device, 04/01/04.
  38. Wilkinson D. MRI and withdrawal of life support from newborn infants with hypoxic-ischemic encephalopathy. Pediatrics 2010; 126(2): e451-e458.
  39. Yuh EL, Barkovich AJ, Gupta M. Imaging of ependymomas: MRI and CT. Child’s Nervous System 2009; 25(10): 1203-1213.

COMMITTEE APPROVAL:

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

GUIDELINE UPDATE INFORMATION:

07/26/01

New Medical Coverage Guideline.

08/15/01

Annual review of Investigational status – no changes.

08/15/02

Reviewed. Revised to include National Medicare coverage change to non-covered (investigational). Added references.

09/15/03

Annual review. Maintain investigational status.

10/15/05

Annual review. Revised Medical Coverage Guideline from investigational to medically necessary when used to differentiate residual brain tumor from post-therapy changes (e.g., delayed radiation necrosis); or differentiate brain tumor from other non-tumor diagnoses (e.g., abscesses or other infectious or inflammatory processes). Revised description. Updated other section, added other names used to report MRS. Updated references.

07/15/06

Scheduled Review. Added investigational statement for non-covered conditions: epilepsy, Alzheimer’s disease, Parkinson’ disease, multiple sclerosis, bipolar disorder, prostate cancer, diagnosing unexplained chest pain, detection and monitoring of neurometabolic diseases, disorders of muscle, and breast lesions. Deleted Medicare Advantage products program exception. Updated references.

07/01/07

Updated Program Exception section.

08/15/07

Review, coverage statements maintained, guideline reformatted, references updated.

01/21/08

Updated Program Exceptions.

07/15/08

Scheduled reviewed. No change in position statements. Added magnetic resonance spectroscopy imaging (MRSI) to the other section. Updated references.

07/01/09

Updated BCBSF Radiology Management program exception; 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 and added BlueSelect.

09/15/09

Annual review. Maintain position statements. Added Medicare program exception. Updated references.

8/15/11

Updated BCBSF Radiology Management Program exception.

09/15/11

Annual review. Updated description section; deleted information regarding the study of MRS. Maintain position statements. Updated references.

12/15/13

Annual review. Maintain position statements. Added FEP and Medicare program exception. Updated references.

01/01/15

Scheduled review; maintain position statement. Updated references.

Date Printed: June 24, 2017: 11:28 AM