February 2024 - High-Tech Radiology Medical Policy Updates Form

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MRI (Magnetic Resonance Imaging) of Head/Brain
Medical Policy

Service: MRI (Magnetic Resonance Imaging) of Head/Brain

PUM 250-0060-1812

Medical Policy Committee Approval 11/30/2023 Effective Date 01/01/2024 Prior Authorization Needed Yes Related Medical Policies: Description:

• Head and brain magnetic resonance imaging (MRI) is a non-invasive imaging technique that uses a strong magnetic field and radio waves to create detailed images of the brain and surrounding tissues. • MRI is also used to monitor the response to treatment for a variety of head and brain conditions. For example, MRI can be used to assess the effectiveness of chemotherapy or radiation therapy for brain tumors. MRI can also be used to monitor the progression of multiple sclerosis or to assess the response to treatment for hydrocephalus. • Medically necessary means that the service is necessary for the prevention, diagnosis, or treatment of a medical condition or injury.

Indications of Coverage: MRI of the Head or Brain is considered medically necessary for ANY of the following indications:

1. Neurological Symptoms: a. Headache. One-time MRI of the head is considered medically necessary for one or more of the following reasons: i. Evaluation of unexplained and persistent headache with a frequency of at least three episodes per month and severe intensity, or documented interference with daily activities or ADLs

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(activities of daily living) EXCEPT for typical migraine with a normal neurologic exam, with or without aura (1, 2). ii. Chronic headache with a change in frequency, severity, or duration). iii. Cluster headaches or other trigeminal-autonomic cephalgias, including paroxysmal hemicrania, hemicrania continua, short- lasting unilateral neuralgiform headache attacks. (1) iv. Acute headache, sudden onset and one or more of the following:

1. Personal history or 1st degree relative with brain aneurysm or AVM (arteriovenous malformation).
2. Extreme pain (“worst headache in my life”) or “thunderclap”-type headache.
3. Prior history of stroke or intracranial bleed.
4. Known coagulopathy or on anticoagulation.
5. Focal neurologic findings, including, but not limited to changes in mental status or motor, sensory, speech or visual deficits, gait disturbance, acute lack of dexterity/coordination, or evidence of elevated intracranial pressure.
6. Cancer
7. Immunocompromise, including pregnancy or puerperium. (18)
8. Subacute head trauma
9. Severe unilateral headache with radiation to or from the neck, associated with suspicion of carotid or vertebral artery dissection.
10. Progressively worsening. (19)
11. New onset of headache and age at least 50 years old.
12. Headaches strictly related to exertional activity (such as sexual activity, exercise, or Valsalva maneuver).
    v. Pediatric patient with persistent headache and one or more of the following:
13. Occipital headache
14. Age <6 years

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3. Symptoms indicative of increased intracranial pressure, such as recurring headaches after waking.
4. Underlying disease that predisposes to intracranial pathology, including, but not limited to immune deficiency, sickle cell disease, neurofibromatosis, history of neoplasm, coagulopathy, hypertension, congenital heart disease (documentation must specify the condition and predisposition). vi. Clinical suspicion of CSF leak supported by patient history or physical exam findings. b. Evaluation of unexplained focal neurological deficits or change in existing deficits. (17) c. New onset of dementia or cognitive impairment of unclear cause.

5. Known or suspected seizure disorders: a. Initial assessment of patients with a first unprovoked seizure (5, 6) excluding any of the following in a pediatric population: simple febrile seizures, idiopathic focal or generalized epilepsy with typical features, BECTS (benign epilepsy with centrotemporal spikes), childhood absence epilepsy (CAE), juvenile absence epilepsy (JAE), and juvenile myoclonic epilepsy (JME) (25). b. Ongoing management of epilepsy when additional information from MRI is required due to a change in clinical condition (7, 8), and EITHER of the following:
   • Change in seizure pattern. • Status epilepticus c. Seizures refractory to medical management.

6. Known or suspected cranial trauma with any of the following: a. Evaluation of head trauma when there is a suspicion of intracranial injury (9, 10). b. Monitoring of traumatic brain injury patients for complications or with new cognitive or neurologic deficits (11, 12). c. Post concussive syndrome if persistent or disabling symptoms and MRI has not been performed already. (20)

7. Known or suspected tumors with any of the following:

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a. Detection and characterization of intracranial neoplasms with one or more of the following: (13, 14) i. Acute, new, or fluctuating neurologic symptoms including, but not limited to changes in mental status, or motor, sensory, speech or visual deficits, gait disturbance, acute lack of dexterity/coordination, or evidence of elevated intracranial pressure. ii. Suspected brain metastasis or intracranial involvement in patients with a history of cancer based on neurological symptoms or examination findings (may include new or changing lymph nodes). iii. Further evaluation of lesions noted on other imaging or incidentally discovered. b. Central diabetes insipidus c. Precocious puberty with hormonal studies suggesting a central cause. (23) d. Pituitary apoplexy with sudden onset of neurological and hormonal symptoms. e. Follow-up of patients with known brain lesions to assess for progression or response to treatment, or with suspected recurrence of previously treated conditions. f. Screening for non-CNS Cancers and Hereditary Cancer Syndromes in accordance with NCCN guidelines. g. Screening in the following known conditions: (39, 40) i. Multiple Endocrine Neoplasia, Type 1 (MEN1), brain MRI every 3-5 years from age 5 years. ii. Tuberous Sclerosis (TS), MRI of brain and abdomen every 1-3 years until age 25. iii. Hereditary Paraganglioma-Pheochromocytoma Syndromes (PGL Syndrome), annual whole-body MRI starting at age 8. iv. Li-Fraumeni Syndrome (LFS), annual screening through lifetime. v. Von Hippel Lindau (VHL) disease, biannual screening, starting at age 10. vi. Neurofibromatosis type 1 (NF1), annual screening.* vii. Neurofibromatosis type 2 (NF2), annual cranial and spinal MRI for ages 10 to at least 40 (thereafter as needed to follow-up).

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viii. Other genetic/hereditary cancer syndromes when consistent with published clinical guidelines when the provider submits the published guidelines for medical director review. h. Follow up of known Rathke cleft cyst (24) i. If no symptoms, MRI at 1, 3, and 5 years after diagnosis. ii. With new neurological symptoms or atypical imaging features. iii. Post treatment, yearly for 5 years. i. Follow-up of known arachnoid cyst (29) i. In patients < 4 years old, serial imaging is warranted. ii. In patients > 4 years old, repeat imaging only if newly symptomatic, increased intracranial pressure, hydrocephalus, local mass effect, seizures, or visual or endocrine dysfunction. j. For follow-up of known pineal cyst, at least 5 mm in size, with associated symptoms, or for one time follow-up of a pineal cyst at least 5 mm in size, with atypical imaging features. k. Midline dermoid cysts/sinuses with concern for intracranial extension. l. Other evaluation or monitoring of cancers explicitly recommended by NCCN guidelines.

5. Vascular Abnormalities. MRI of the head is considered medically necessary for one or more of the following reasons: a. Assessment of known or suspected vascular conditions, such as aneurysms, arteriovenous malformations, or ischemic events. (16) b. Known or suspected stroke with signs or symptoms including, but not limited to partial or complete aphasia, ataxia, decreased level of consciousness, dysarthria, monocular blindness, parasthesias (unexplained), visual loss, unilateral sensory or motor loss, transient global amnesia. c. Known or suspected transient ischemic attack (TIA). d. Known or suspected venous thrombosis. e. Suspected temporal arteritis in a patient > 50 with ANY of the following, temporal headache, abrupt visual changes, jaw claudication, temporal artery tenderness, constitutional symptoms or elevated ESR; (27) AND Either a Negative initial work-up by color Doppler ultrasonography or biopsy) OR Atypical features, failure to respond to treatment or specific concern for intracranial involvement.

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6. Evaluation of suspected or known demyelinating diseases, such as multiple sclerosis and ANY of the following a. For initial evaluation (diagnosis) of a patient with clinical suspicion of MS based upon either a clinically isolated syndrome (such as optic neuritis) or recurring episodes of unexplained neurologic deficits OR for a single repeat study after at least 6 months to document progression/dissemination in time. b. Need for baseline imaging, postpartum, or 3-6 months following change in disease modifying therapy. c. One-time 6-month repeat scan in patients with MRI disease activity that is not associated with new clinical symptoms (i.e., Radiographically isolated syndrome). (26) d. New neurologic signs or symptoms with concern for progression of disease. e. Prior to initiation of, or prior to revision of, disease modifying therapy. f. Surveillance imaging every 1-2 years.
   g. If known or suspected or high risk for PML (Progressive Multifocal Leukoencephalopathy), every 3-4 months.
7. Evaluation of suspected or known central nervous system (CNS) infections, and ANY of the following: a. CNS infection/abscess/meningitis/encephalitis based clinical exam, OR mental status changes, stiff neck OR with positive lab findings (such as elevated white blood cells or abnormal lumbar puncture fluid exam). b. Endocarditis with suspected septic emboli. c. Central Nervous System (CNS) involvement in patients with known or suspected vasculitis or autoimmune disease with abnormal inflammatory markers or autoimmune antibodies.
8. Evaluation of suspected or known neurodegenerative diseases, such as Alzheimer's disease, Parkinson's disease, and any of the following: a. Cognitive impairment of unknown etiology, memory loss, or changes in mental status (3, 4) including unexpected changes in existing symptoms or clinical course. b. Aducaumab (Aduhelm, aducanumab-avwa) therapy for Alzheimer disease, (30) when approved for this therapy through pharmacy benefit. i. Prior to initiation, if a brain MRI has not been obtained in the prior 12 months.

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ii. Before the 7th infusion (approximately 12 weeks). iii. Before the 12th infusion. (30) c. For evaluation of suspected Parkinson’s with atypical features or unresponsive to levodopa. d. For evaluation of new non-Parkinson neurological symptoms in known Parkinson’s disease complicating the evaluation of the current condition. e. For the evaluation of other movement disorder to exclude a structural lesion (i.e., suspected Huntington disease, chorea, atypical parkinsonian syndromes, hemiballismus, atypical dystonia). (28)

9. Evaluation of suspected or known congenital anomalies of the brain and spine
10. Evaluation of suspected or known hydrocephalus
11. In the postoperative period following shunt placement or ETV (endoscopic third ventriculostomy), with further follow-up imaging 6-12 months after the procedure and then every 12 months for individuals with stable clinical findings OR when shunt malfunction or infection is suspected.
12. Evaluation of suspected or known pituitary gland disorders with one or more of the following: a. Hypopituitarism b. Growth hormone deficiency c. Hypogonadotropic hypogonadism [low sex hormones and gonadotropins (FSH/LH)] (21) d. Central hyperthyroidism (high TSH) e. Cushing syndrome suspected (high ACTH (>5) with cortisol suppression on low or high dose dexamethasone suppression test). f. Acromegaly/gigantism with high GH/IGF-1 g. Elevated prolactin (22)
13. Evaluation of suspected or known cranial nerve or spinal accessory nerve disorders and ANY of the following: a. Known or suspected optic neuritis. b. Eye abnormalities including any of the following (31-35): i. Papilledema ii. Nystagmus iii. Optic atrophy

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iv. Ocular nerve palsy v. New onset anisocoria vi. New Visual field defects vii. Binocular diplopia viii. Childhood strabismus in the presence of developmental delay or abnormal funduscopic exam. c. New onset of Horner Syndrome, or initial evaluation of congenital Horner Syndrome. d. Atypical occipital neuralgia e. Bell’s palsy and ANY of the following (36): i. Atypical presentation ii. >3 weeks slow resolution iii. No improvement at 4 months iv. Facial twitch or spasms at onset f. Cranial nerve palsy

14. Evaluation of suspected or known acoustic neuroma
15. One time imaging for the evaluation of suspected or for reevaluation of known Chiari malformation with new or changing signs/symptoms or physical exam findings.
16. Diagnosis and follow up of known or suspected neurosarcoidosis
17. Pre-operative and post-operative imaging for neurosurgical procedures
18. Evaluation of suspected or known inner ear disorders
19. Further evaluation when needed based on CT or x-ray imaging or cranial ultrasound.

20. Brief Resolved Unexplained Event (BRUE/ALTE) in an infant when history or exam are concerning for a neurologic cause. (37) Limitations of Coverage:

    A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

    B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be denied as experimental, investigational, and unproven to affect health outcomes.

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C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be denied as not medically necessary.

D. Head and brain MRI is not medically necessary for the following:

a. Screening for asymptomatic patients who are at low risk for head and brain disease. b. Monitoring stable patients with known head and brain disease. c. Guiding invasive procedures intraoperatively. d. Research purposes including determining eligibility for participation in clinical trials. e. essential tremor, Tourette’ syndrome, or isolated focal dystonia (e.g., blepharospasm, cervical dystonia, laryngeal dystonia, oromandibular dystonia, writer’s dystonia). f. MRI of the brain for autism, unless there are new or worsening neurological findings, developmental regression, or if any of the Indications of Coverage (above) are met.
g. For migraine with normal neurological exam and none of the conditions listed in Indications of Coverage (above).

Documentation Required: To obtain prior authorization, the requesting provider must submit the following information: • The patient's medical history and physical examination findings • The specific indication for head and brain MRI • The results of any other relevant tests, such as CT scan, EEG, or spinal tap

Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com.

Policy Review History:

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Implemented 01/01/2024 Medical Policy Committee Approval 11/30/2023 Reviewed

11/30/2023 Revised 02/23/2024 effective 04/23/2024 Developed 11/30/2023

Approved by the Medical Director

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MRI (Magnetic Resonance Imaging) of the Breast Medical Policy

Service: MRI Breast

PUM 250-0051-1812

Medical Policy Committee Approval 10/26/2023 Effective Date 01/01/2024 Prior Authorization Needed Yes

Related Medical Policies:

Description: Magnetic Resonance Imaging (MRI) of the breast is commonly used in conjunction with mammography and/or ultrasound but may also be used as a “stand- alone” imaging technique of the breasts. It is mostly used in the screening, diagnosis, or characterization of breast cancer.

Indications of Coverage:

MRI of the Breast is considered medically necessary when at least ONE of the following criteria are met:

I. Known Breast Cancer and at least ONE of the following:

A. Evaluation of invasive breast cancer (ductal or lobular):

• for initial staging when mammography/ultrasound is indeterminate in defining the extent of cancer, OR
• whether the tumor is multifocal/multicentric, OR
• with size discrepancy between tumor size on imaging versus physical exam.

B. Presurgical localization is needed.

C. Evaluation of tumor after neoadjuvant (preoperative) chemotherapy for planning of breast conserving surgery.

D. Evaluation of tumor prior to neoadjuvant chemotherapy to serve as a baseline.

E. With newly diagnosed breast cancer and need to evaluate the contralateral breast, provided contralateral breast mammography is either negative or indeterminate.

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F. For staging of disease with high risk or suspicion of occult disease (such as ER/PR neg and Her2neu neg tumor, or with underlying BRCA mutation).

G. For more thorough evaluation of biopsy proven atypical ductal hyperplasia, OR lobular neoplasia (lobular carcinoma in situ, OR atypical lobular hyperplasia), when extent of disease is not adequately defined by mammography, ultrasound or physical exam.

H. To evaluate extent of disease after biopsy-proven Paget’s disease of nipple/areola.

I. Post surgical follow-up AND either:

• suspected tumor recurrence at lumpectomy site, provided mammogram is negative or indeterminate, OR
• with positive or close surgical margins after lumpectomy, to assess for residual disease, OR
• screening in the contralateral breast in patient with BRCA mutation.

II. Further Evaluation of Breast abnormality, when at least ONE of the following are met:

A. Breast lesion is ALL of the following:

• nonpalpable
• equivocal on mammography
• not visible on Ultrasound (or ultrasound indeterminate)
• not amenable to mammographic, stereotactic, or ultrasound guided fine needle biopsy.

B. Breast lesion for which anatomic guidance is needed for biopsy, with mammographic and ultrasound findings indeterminate or equivocal.

C. In a patient with asymptomatic silicone breast implants, to evaluate for leak or rupture of implant, or complication of implant, ONLY if mammography and/or ultrasound results are either abnormal or indeterminate regarding implant integrity. (Provided the implants were not placed as part of a purely cosmetic surgery, in which case health plan certificate language may not provide coverage.) **

D. In a patient with symptomatic silicone breast implants, MRI is medically necessary, and a preceding mammogram or ultrasound is not required. (Provided the implants were not placed as part of a purely

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cosmetic surgery, in which case health plan certificate language may not provide coverage.) **

E. New nipple inversion or skin changes suspicious for inflammatory breast cancer or unilateral bloody or serous nipple discharge, with inconclusive mammography and ultrasound.

F. With negative/indeterminate mammography, with no palpable mass, but suspected Paget Disease, with either bleeding, eczema, itching, or ulcer of the nipple or areola.

G. Suspicious mass or breast distortion/abnormality in a patient with history of breast cancer, and other imaging is indeterminate.

H. For biopsy proven phylloides tumor, to determine extent of disease and for preoperative planning.

I. For follow-up of a lesion characterized as BI-RADS 3, probably benign, and not seen on prior mammography or ultrasound, and only seen on MRI. One follow-up MRI is considered medically necessary after a prior indeterminate MRI and further surveillance MRI would only be medically necessary if the latest MRI was interpreted as highly suspicious, or if a significant interval change was noted.

III. For Breast Cancer Screening* with no personal history of breast or ovarian cancer and at least ONE of the following A.—E.:

A. Personal history of mutation in one of the high-risk breast cancer genes (specifically, BRCA1, BRCA2, TP53, PTEN, ATM, BARD1, CDH1, CHEK2, NF1, PALB2, STK11, RAD51C, RAD51D).

B. Lifetime risk of breast cancer of at least 20%, based on validated risk assessment models, such as Gail (Breast Cancer Risk Assessment Tool), Claus, Tyrer-Cuzick, or BRCAPRO.

C. Personal history of chest irradiation between the ages 10 and 30 years old.

D. Inconclusive screening mammogram (Category 0) due to extremely dense breast tissue or tissue obscuration from implants.

E. Personal history of ONE of the following syndromes:

• Peutz-Jeghers

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• Li-Fraumeni
• Cowden syndrome
• Bannayan-Riley-Ruvalcaba syndrome

• Hereditary diffuse gastric cancer with CDH1 mutation

IV.
Family history of ONE of the following:

A. No prior personal genetic testing, but parent, sibling or child with documented BRCA1 or BRCA2 mutation.

B. Breast cancer in a male relative

C. Parent, sibling or child with ONE of the following syndromes:

• Peutz-Jeghers
• Li-Fraumeni
• Cowden syndrome
• Bannayan-Riley-Ruvalcaba syndrome
• Hereditary diffuse gastric cancer with CDH1 mutation

V.
For Breast Cancer Annual Screening with a personal history of Breast

cancer and ANY of the following:

A. breast cancer diagnosed before age 50.

B. mammographically dense tissue.

C. personal history of mutation in high-risk breast cancer genes (BRCA1, BRCA2, TP53, PTEN, ATM, BARD1, CDH1, CHEK2, NF1, PALB2, STK11, RAD51C, RAD51D).

D. primary breast cancer which had been mammographically occult (not detected on earlier mammography).

VI. To evaluate for occult breast cancer with biopsy proven adenocarcinoma, no

known primary, with ALL of the following:

A. negative mammography

B. negative breast ultrasound

C. no palpable breast lumps (for example, biopsy proven axillary node adenocarcinoma but no known breast primary tumor).

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VII. Repeat Breast MRI when clinically needed:

A. prior to or after completion of an invasive procedure OR

B. for interval reassessment or changing clinical status, when results will impact treatment.*

*Guidelines for periodic repeat high risk screening testing:

A. With lifetime breast cancer risk at least 20%, annual MRI is considered medically necessary at age 40, or ten years prior to the youngest family member age at breast cancer diagnosis, but not before age 25.

B. With personal history of atypical ductal hyperplasia or lobular neoplasia (lobular carcinoma in situ/atypical lobular hyperplasia), annual MRI is considered medically necessary from the time of diagnosis, but not before the age of 25.

C. With personal history of previous chest irradiation between ages 10 and 30, annual MRI is considered medically necessary after age 25 and at least 8 years after completion of radiation.

D. With known personal history of BRCA1 or BRCA2 mutation, or with no personal prior BRCA testing, but with known BRCA mutation in sibling, parent or children, annual MRI after age 25 is considered medically necessary.

E. With personal history of breast cancer linked genes, annual MRI is considered medically necessary for ANY of the following:

• beginning at age 30 for mutations in CDH1, CHEK2, PALB2, ATM, NF1 (ending at age 50 for NF1), STK11 (Peutz-Jeghers).
• beginning at age 40 for RAD51C, RAD51D, BARD1
• for TP53 (Li-Fraumeni), beginning at age 20 or at age of earliest familial breast cancer, if that was less than 20.
• for Cowden syndrome or Bannayan-Riley-Ruvalcaba, beginning at age 35, or ten years prior to the age of earliest breast cancer diagnosis in the family.

F. With a personal history of breast cancer and at least ONE of the criteria under V. A.-D. above, annual surveillance/screening MRI is considered medically necessary.

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**Prior to any approval of Breast MRI for silicone implants, check member certificate for potential general exclusion for services related to a noncovered service. If the implants were placed for cosmetic purposes (and not breast cancer related), then complications of those implants, and imaging of those complications, may not be a covered benefit.

Limitations of Coverage:

A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be denied as experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be denied as not medically necessary.

D. Breast MRI for cancer screening before the age of 25 is considered not medically necessary.

E. Breast MRI for evaluation of suspected complications of saline breast implants is considered not medically necessary.

F. Breast MRI for the evaluation of asymptomatic silicone implants is considered not medically necessary, unless either mammography or ultrasound results are either abnormal or indeterminate regarding implant integrity.

G. Screening/Surveillance Breast MRI more frequent than every 12 months is considered not medically necessary.

H. More than one follow-up breast MRI for reevaluation of a previously indeterminate MRI finding is not medically necessary unless the latest Breast MRI showed an interval change or was interpreted as highly suspicious.

Documentation Required:

Prior authorization is required for all breast MRI procedures. To obtain prior authorization, the requesting provider must submit the following information:

• The patient's medical history and physical examination findings • The specific indication for breast MRI • The results of any other relevant tests

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Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com.

Policy Review History:

Implemented 01/01/2024 Medical Policy Committee Approval 10/26/2023 Reviewed

10/26/2023 Revised 02/23/2024 effective 04/23/2024 Developed 10/26/2023

Approved by the Medical Director

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MRI (Magnetic Resonance Imaging) of the Spine (Cervical, Thoracic, Lumbar) Medical Policy

Service: MRI of the Spine (Cervical, Thoracic, Lumbar)

PUM 250-0057-1812

Medical Policy Committee Approval 10/26/2023 Effective Date 01/01/2024 Prior Authorization Needed Yes

Related Policies:

Description: Magnetic Resonance Imaging (MRI) of the spine provides high contrast imaging of the spine and allows for high resolution evaluation of the spinal cord and surrounding structures. It is commonly used to evaluate for disc pathology, abnormalities of the spinal cord and thecal sac, and the bones of the spinal column.

Indications of Coverage:

MRI of the Spine (Lumbar, Thoracic, or Cervical) is considered medically necessary when at least ONE of the following criteria are met:

A. Back or neck pain when at least ONE of the following is met:

i. a “red flag” indication listed below
ii. new or worsening neurologic deficits* noted on physical exam. iii. Electromyography or nerve conduction studies (EMG/NCV) indicative of radiculopathy. iv. Symptoms which have not responded to at least a six-week trial of conservative treatment within the last 6 months or during the current episode of pain (as described below). ***
v. Progression or worsening of symptoms during a trial of conservative treatment.

*In the presence of “red flag” findings, MRI of the spine should be approved as medically necessary, and no trial of active conservative treatment is required. “Red Flag findings” include:

a) new or unexplained motor weakness.
b) new sensory deficits (pinprick, touch, vibration, temperature) in a dermatomal distribution and unlikely to be due to peripheral neuropathy).

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c) cauda equina syndrome d) suspected infection e) severe radicular pain (e.g., prompting ED/UC visit) f) new or unexplained bowel or bladder dysfunction (unrelated to bowel or bladder disorder) g) back or neck pain at age 5 or younger h) unexplained pediatric limping or refusal to walk.

** Neurologic deficits on physical exam include:
a) unexplained muscle weakness (to include foot drop) not likely to be due to peripheral neuropathy.

b) new sensory deficits (pinprick, touch, vibration, temperature) in a

dermatomal distribution and unlikely to be due to peripheral neuropathy).
c) abnormal upper motor neuron signs, such as unexplained Lhermitte’s or
Babinski’s or Hoffmann’s signs, or unexplained hyperreflexia or unexplained bilateral motor weakness.
d) new, abnormal deep tendon reflexes, unlikely to be due to peripheral neuropathy.
e) new onset of bowel or bladder incontinence or retention (unlikely related to inherent process in the bowel or bladder).
***A trial of conservative treatment is defined as a combination of both active and inactive components, dedicated to the area of interest during the current episode of pain. Inactive components include medications (such as analgesics, anti-inflammatory medications, muscle relaxants), rest, ice, heat, or injections/acupuncture. Active modalities include either Physical Therapy, Chiropractic or osteopathic manipulations, or a physician assisted home exercise program.

B. For evaluation of spondylolysis/spondylolisthesis, MRI of the lumbar spine is considered medically necessary if either:

a) adult patient and alternate imaging (plain films, Bone scan, CT) is indeterminate or additional information needed. (Unless one of the indications in A. i.-v. (above) is met, a trial of conservative treatment is required), OR
b) pediatric population when alternate imaging is inconclusive and additional imaging would alter management.

FOR EACH OF THE FOLLOWING, C--T, A TRIAL OF CONSERVATIVE THERAPY IS NOT REQUIRED:

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C. Back or Neck Pain with abnormal EMG, suggestive of radiculopathy. No trial of conservative treatment is required; however, a repeat MRI will be deemed not medically necessary in the absence of new or changing clinical findings.

D. Trauma/Compression Fractures –With fracture documented on plain films and/or CT and ONE of the following:

i. Pathologic fractures
ii. Complex fractures
iii. Trauma and associated neurologic deficits
iv. Trauma and obtunded patient and spine or nerve root injury suspected.
v. Findings from x-rays or CT require further evaluation.

NOTE: In the setting of acute trauma, preceding plain films or CT are not required with EITHER a) associated neurologic deficits; OR b) obtunded patient and spinal or nerve root injury suspected.

E. Inflammatory spondylitis, such as ankylosing spondylitis/spondyloarthropathy or diffuse idiopathic skeletal hyperostosis and:

i. plain films are not diagnostic, or are equivocal OR
ii. new neurologic symptoms or with a patient who cannot be optimally evaluated clinically.

F. Known or new compression fracture noted on x-rays and/or CT, but additional information required for ONE of the following:

i. MRI needed to help distinguish osteoporotic, benign fracture from metastatic/myelomatous disease (if initial MRI is indeterminate in this setting, repeat MRI in 6 weeks may be approved).
ii. with new focal neurologic deficit
iii. to determine the position of fracture fragments.
iv. to assess union of the fracture when delayed or nonunion is suspected (CT is typically preferable).
v. prior to surgery/intervention/vertebral augmentation, when the MRI results may change treatment plan.

G. Multiple Sclerosis or other demyelinating/inflammatory processes, to include transverse myelitis, and acute disseminated encephalomyelitis (ADEM)--- MRI of cervical and Thoracic spine is considered medically necessary (trial of conservative treatment not required) if any of the following are met:

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i. with findings suggestive of MS on recent brain MRI, and prior spinal imaging has not yet been completed.
ii. high clinical suspicion of MS, but the brain MRI results are inconclusive/indeterminate.
iii. MS is either known or suspected, and there are new or changing symptoms suggesting spinal cord involvement.
iv. to assess disease extent prior to initiating disease modification treatments.
v. prior to changing disease modification treatments, to establish a new baseline.
vi. for follow-up of known MS, within 6-12 months of initiating or changing treatment with disease modifying medications. vii. clinical symptoms suggestive of either transverse myelitis or neuromyelitis optica. viii. suspected or known pediatric demyelinating disease, to include acute disseminated encephalomyelitis.
ix. Clinical suspicion of Guillain-Barre Syndrome with non-diagnostic CSF studies and EMG/Nerve Conduction studies.

H. For evaluation of tumor /metastasis. For primary spinal tumor, for initial staging, or repeat exams with either:

i. follow-up within one year of active treatment, or for surveillance as suggested by NCCN.
ii. known tumor and new focal neurologic deficit or new signs/symptoms (increasing pain, lab/other CT/x-ray/bone scan findings) suggesting disease progression.

For Metastatic Tumor:

i. new focal neurologic deficit or new signs/symptoms (increasing pain,) OR
ii. lab/other CT/x-ray/bone scan findings suggesting disease progression OR iii. evidence of metastasis on bone scan or other imaging, and further clarification needed, OR
iv. known malignancy with new signs/symptoms suggesting metastatic disease, OR
v. for evaluation of suspected drop metastases or of leptomeningeal carcinomatosis.

I. Post-Operative spinal disorders---For clinical findings suggestive of CSF leak, or suspected post op infection, or for new or worsening symptoms/neurologic deficits after surgery. Routine post operative surveillance imaging, without symptoms, is considered not medically necessary, and requests for post

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operative imaging must document why the additional imaging is needed/requested.

J. Indeterminate findings on prior imaging AND:

i. initial, more definitive imaging is needed, OR
ii. one follow-up exam following an indeterminate MRI/CT to assess for interval change.

K. Suspected Infection (disc space infection, epidural abscess, spinal osteomyelitis), provided there are either abnormal signs/symptoms or laboratory findings (such as leukocytosis or elevated ESR/CRP) or suggestive alternate imaging. For follow-up of known infection with worsening symptoms/laboratory values, or to monitor post-operative results.

L. Spinal Dysraphism/Tethered Cord-- For initial imaging of known Arnold- Chiari syndrome, one time MRI Cervical, Thoracic, Lumbar spine is medically necessary, or for follow-up with new or changing signs/symptoms.

M. Suspected Myelopathy--If high clinical suspicion of myelopathy (such as unexplained Lhermitte’s or Babinski’s or Hoffmann’s signs), or unexplained limb hyperreflexia or unexplained bilateral motor weakness, or progressive worsening of symptoms, to include hand clumsiness, difficulty grasping objects, worsening balance/ambulation, diffuse numbness/tingling in bilateral hands, MRI of Cervical and Thoracic spine is considered medically necessary.

N. Suspected syringomyelia-- MRI cervical and thoracic is considered medically necessary, when syringomyelia is clinically suspected due to neurologic findings or due to predisposing conditions such as Chiari malformation, prior trauma, neoplasm, arachnoiditis, or to better characterize an abnormality/suspected syrinx seen on other imaging. Follow-up MRI is medically necessary with known syrinx and new/worsening signs/symptoms.

(If MRI cervical detects syrinx, then MRI brain and MRI Thoracic spine are

medically necessary to assess for inferior extent of syrinx and evaluate for

potential syringobulbia).

O. Scoliosis/Kyphosis—when the following are met:

a) plain radiographs have been obtained, AND
b) one of the following:

i. needed for preoperative planning.

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ii. with suspected underlying cord abnormalities (syrinx, diastematomyelia, tethered cord) or tumors, to include convex left thoracic curve, greater than 30-degree kyphosis. iii. with associated new or unexplained neurologic deficit. iv. child less than 10 years old with congenital or juvenile idiopathic scoliosis.

P. SCS Placement---MRI of thoracic spine is medically necessary, provided MRI of the thoracic spine has not been completed in the past 6 months.

Q. Pediatric Back Pain with documented vertebral anomalies (such as hemivertebra, hypoplasia, butterfly vertebra, congenital wedging).

R. Spasticity or increased muscle tone in the upper or lower extremities or gait abnormalities suspected to be related to myelopathy.

S. MRI Lumbar spine is medically necessary for suspected cauda equina syndrome, with severe back pain and ONE of the following:

i. saddle anesthesia of the pelvis,
ii. bilateral absent Achilles reflexes,
iii. new onset bowel/bladder dysfunction,
iv. absent anal and/or bulbocavernous reflexes

T. For pediatric known anorectal malformations, MRI lumbar is medically necessary, if either:

a) suspicious pediatric sacral dimples (i.e., deep or multiple dimples, at or above superior gluteal crease, larger than 5mm, or with associated cutaneous markers) if > 3 months old, OR
b) if less than 3 months old, ultrasound if the preferred imaging, and MRI lumbar is deemed medically necessary only if the ultrasound is indeterminate/inconclusive.

In addition to the indications listed above, a trial of conservative treatment prior to MRI is not required with:

a) isolated back/neck pain in a pediatric population.
b) suspected atlantoaxial instability.
c) for evaluation of rheumatoid arthritis with neurologic signs/symptoms or subluxation detected on flexion/extension radiographs.

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NOTE: The need for concurrent, similar studies, such as MRI and CT, require documentation of medical necessity for preoperative surgical planning, with requirement for both bony and soft tissue anatomic evaluation.

If MRI of the entire spinal cord is indicated, cervical and thoracic spine will be approved, but MRI of the lumbar spine will be denied as not medically necessary, unless there is documentation of known or suspected low-lying conus medullaris. The conus typically ends at the L1 level and will be included in thoracic spine imaging.

For pre and postoperative planning/evaluation, MRI is typically preferable for evaluating the spinal cord, nerve roots, and for disc pathology and post-op infection, whereas CT is typically preferable for evaluating the bones, hardware complications, and to determine extent of fusion, or possible pseudoarthrosis.

If a combination request (for example MRI cervical AND thoracic spine) is requested, medical records must document why overlapping imaging is necessary, unless combination imaging is addressed as medically necessary within this medical policy.

Requests for repeat MR imaging, after completing MR of the same anatomic site in the past 6 months, will be reviewed on a case-by-case basis. The most recent imaging reports must be submitted, and for the repeat exam to be approved as medically necessary, ONE of the following MUST be met:

a) documentation that the prior testing was inconclusive or with short-term follow-up imaging recommended. b) clinical documentation of progressive worsening of symptoms or new physical exam findings prompting the repeat imaging, and that patient management will be altered by the imaging results. c) interval surgery (with suspected complication) or significant new trauma to that anatomic region.

Limitations of Coverage:

A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be denied as experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be denied as not medically necessary.

D. Positional MRI (dynamic, kinetic, weight-bearing) of the spine is deemed experimental, investigational, unproven, as there is inadequate supportive evidence-based literature.

E. For 3D Rendering, refer to 3D Rendering of MRI, CT, US Medical Policy.

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F. MRI of lumbar spine is considered not medically necessary for placement of a spinal cord stimulator (MRI of thoracic spine is considered medically necessary).

G. For evaluation of suspected myelopathy or multiple sclerosis (MS), MRI of the lumbar spine is considered not medically necessary, unless other than the Lumbar spine is being imaged for other reasons that meet the policy under Indications of Coverage above.

H. Spinal imaging as a routine follow-up for MS, more frequent than every 1-2 years, is considered not medically necessary, unless there have been new or changing symptoms or changes made in disease modifying treatments.

I. Routine postoperative surveillance imaging, without clinical symptomatology, is considered not medically necessary.

J. Use of low field MRI for evaluation of the spine is considered experimental, investigational, unproven.

Documentation Required:

Prior authorization is required for all spinal MRI procedures. To obtain prior authorization, the requesting provider must submit the following information:

• The patient's medical history and physical examination findings • The specific indication for spinal MRI • The results of any other relevant tests

Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com.

Policy Review History:

Implemented 01/01/2024 Medical Policy Committee Approval 10/26/2023 Reviewed

10/26/2023 Revised 02/23/2024 effective 04/23/2024 Developed 10/26/2023

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Approved by the Medical Director

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MRI (Magnetic Resonance Imaging) of Upper and Lower Extremities Medical Policy

Service: MRI of Upper and Lower Extremities

PUM 250-0058-1812

Medical Policy Committee Approval 10/26/2023 Effective Date 01/01/2024 Prior Authorization Needed Yes

Related Medical Policies:

Description: Magnetic Resonance Imaging (MRI) of the extremities and musculoskeletal system allows for imaging of joints and adjacent structures without the use of radiation.
It provides high contrast and spatial resolution, allowing for detection of abnormalities of bone, cartilage, ligaments, tendons, and pathology of the periarticular structures and muscles.

Indications of Coverage:

MRI of the Upper or Lower Extremities is considered medically necessary when at least ONE of the following criteria are met:

The following applications (A. through N.) of musculoskeletal MRI apply to both the upper and lower Extremity.

A. Non-Contrast MRI for Trauma/ Fracture is considered medically necessary for ANY of the following:

a. better evaluation of comminuted or displaced fracture seen on plain radiographs (x-rays), or for presurgical planning.

b. for suspected acute, occult scaphoid fracture or hip/femoral neck fracture or Lisfranc Fracture-dislocation of the midfoot and initial radiographs are not definitive, or do not demonstrate a clinically suspected fracture.

c. stress/insufficiency or occult subacute fractures when clinical exam and plain radiographs are not definitive and EITHER:

1) x-rays nondiagnostic after ten days conservative treatment OR
2) initial x-rays obtained at least 14 days after injury/ onset of

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symptoms are non-diagnostic, or do not demonstrate a clinically suspected stress fracture.

d. for suspected shin splints/stress reaction only if x-rays are non-diagnostic AND there has been failure of a four-week trial of provider-directed conservative care. **Repeating an MRI within 3 months after an initial MRI showing stress fracture/stress reaction is not medically necessary.

e. for suspected delayed union/nonunion of fracture/osteotomy/surgical fusion and no documented healing on two sets of x-rays at least 4 months apart (typically, CT is preferable).

f. with fracture documented on radiographs/imaging, for suspected associated ligamentous/tendinous injury that may require surgery.

g. to better evaluate a pathologic fracture seen on x-ray or CT.

h. with pathologic lesion (such as metastasis) and concern for impending fracture.

B. MRI for suspected Avascular Necrosis (AVN) is medically necessary when the anatomic site is one of the following: femoral head, distal femur/knee, talus, tarsal navicular, metatarsal head, humeral head, carpal lunate or scaphoid/wrist AND ONE of the following:

a. plain x-rays are negative or indeterminate, but patient is high risk (steroid use, organ transplant, alcohol abuse, sickle cell anemia).

b. plain radiographs are suggestive of or confirmatory of AVN, but MRI needed for appropriate treatment planning.

c. Known osteonecrosis, and need to evaluate contralateral joint, after x- rays obtained.

C. Non-Contrast MRI for Ganglion: When history/physical examination/radiographs do not provide a definitive diagnosis, or when needed for preoperative surgical planning.

D. MRI without and with contrast for Infection:

a. when plain radiographs are negative or non-diagnostic, but soft tissue or bone infection is still suspected, OR

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b. when radiographs are suggestive of infection/osteomyelitis, but MRI needed to evaluate extent of infection, or assess for skip lesions of for liquefied abscess which might be drained, OR

c. suspected septic joint when arthrocentesis is either contraindicated or unsuccessful or non-diagnostic, AND

i. ONE of the following exam findings (warm, swollen joint), decreased ROM, or fever AND
ii. ONE of the following: lab tests, either elevated WBC count, or elevated CRP/sedimentation rate (ESR), or aspiration had been completed, but analysis of joint fluid is nondiagnostic.

d. with septic joint confirmed by aspiration, and MRI needed to determine soft tissue extension and potential skip lesions.

e. soft tissue ulcer (diabetic or pressure or ischemic) or neuropathic joint and clinical signs of infection and osteomyelitis or deep infection/abscess is suspected.

f. for postoperative assessment of complication/possible infection with abnormal physical exam findings (such as fever) or lab findings (leukocytosis, elevated ESR/CRP).

E. MRI of soft Tissue Masses are medically necessary when ONE of the following are met:

a. plain radiographs and/or Ultrasound are negative or indeterminate (radiographs not required in patients with known malignancy), OR

b. to evaluate suspected vascular malformation and results will change management, OR

c. for revaluation, post treatment

F. For Bone or Soft Tissue Lesion /Mass: MRI is medically necessary if ONE of the following are met:

a. radiographs or other imaging (such as bone scan) have been obtained and diagnosis is uncertain based upon plain appearance (radiographs are not required if other imaging, such as bone scan, documents bony lesion).

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b. MRI required for staging of tumor or for biopsy planning or to determine extent of disease for surgical or treatment planning.

c. with known underlying bone tumor/disorder (such as osteochondroma) and malignant degeneration is suspected.

d. for follow-up of known tumor, having been treated in the past 12 months.

e. to evaluate for potential metastases and/or tumor recurrence, and results will alter management. G. For Tendon or Muscle Injury: MRI is considered medically necessary when one of the following is met:
a. Known or suspected acute or subacute partial or complete tendon tear as demonstrated by abnormal or equivocal exam.
b. Trial of 4 weeks of active conservative therapy within the past six months or during the current episode of pain without improvement.**
c. Tendon or muscle injury seen by other imaging and requiring MRI for treatment planning. H. For Osteochondral Injuries (osteochondral fracture/osteochondritis dissecans), MRI is considered medically necessary, provided there is clinical suspicion and x- rays were nondiagnostic, or showed findings requiring additional imaging.
I. MRI is medically necessary for evaluation of loose bodies in the joint, and x-rays were nondiagnostic, or showed findings requiring additional imaging.

J. For Inflammatory arthritis, Including Rheumatoid Arthritis, MRI without and with contrast is medically necessary of the symptomatic joint, or if multiple joints are affected, of the most symptomatic joint if ONE of the following:

a. diagnosis is uncertain.

b. patient has suspected seronegative RA and drug therapy is to be initiated.

c. to assess efficacy of disease modifying anti-rheumatic drug treatment (testing should only be approved for a single joint/anatomic site, and only once, not intended for routine follow-up).

d. to determine if a change in treatment is indicated.

K. With suspected joint prosthesis loosening or dysfunction, MRI is considered medically necessary if ANY of the following are met:

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a. loosening/dysfunction suspected, and radiographs are non-definitive.

b. suspected metallosis with hip pain and metal on metal hip arthroplasty.

c. suspected peri-articular fracture and plain radiographs are not diagnostic.

L. Peripheral Nerve injury/entrapment (such as carpal tunnel syndrome or brachial plexopathy or tarsal tunnel or Morton’s neuropathy), MRI is medically necessary if ONE of the following:

a. EMG or Nerve conduction study is abnormal.

b. failure of 4 weeks of conservative treatment.

M. For evaluation of foreign bodies, if x-ray or ultrasound or CT are non-diagnostic.

N. For diagnosis or biopsy planning of known or suspected inflammatory myopathies (such as dermatomyositis).

O. If none of the above (A-N) are met, MRI of the Upper Extremity (Hand, Wrist, Arm, Elbow, Shoulder) is medically necessary if ONE of the following are met:

a. No joint specific physical exam findings on exam but persisting pain/symptoms with failure of four-week trial of conservative therapy** (PT/Chiro, and/or provider directed HEP) within the past 6 months, OR worsening of symptoms during conservative treatment.

b. Positive site-specific orthopaedic exam findings, to include (but not limited to): i. shoulder—rotator cuff/supraspinatus weakness, drop arm sign, Popeye sign, positive rotation lag, OR positive apprehension, positive clunk test, grind test, or O’Brien’s test (suggesting labral tear). NOTE: Neer or Hawkins test for impingement meet these criteria only if other findings suggest rotator cuff tear, such as asymmetric weakness of shoulder abduction or external rotation.
ii. elbow –such as biceps squeeze test, bicipital aponeurosis flex test. iii. testing suggesting tear of scapholunate ligament or lunotriquetral ligament or press test for TFCC tear.

c. Joint instability on exam or recurrent joint dislocations.

d. marked joint swelling (or joint effusion) after acute trauma and following orthopaedic evaluation.

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P. If none of the above, (A-N) are met, MRI of the lower extremity (bony pelvis, hip, knee, leg, ankle, foot) is medically necessary if ONE of the following are met:

a. No joint specific physical exam findings on exam but persisting pain/symptoms with failure of four-week trial of conservative therapy** within the past 6 months, OR worsening of symptoms during conservative treatment.

b. Positive site-specific orthopaedic exam findings, to include (but not limited to):

i. hip— hip clicking or locking or instability (suggesting labral tear), or positive anterior or posterior impingement sign (suggesting femoroacetabular impingement).
ii. knee— locking or clicking, anterior or posterior drawer sign, Lachman, McMurray or Apley test, abnormal varus or valgus stress, hemarthrosis on joint aspiration.
iii. ankle—positive stress x-rays or drawer sign or Thompson sign (suggesting Achilles tendon tear).

c. marked joint swelling (or effusion seen on x-ray) after acute trauma (such as high ankle sprain, acute internal knee derangement) and following orthopaedic evaluation.

d. Joint instability on exam or recurrent joint dislocations

Q. For any of the following diagnoses, known or suspected, provided that a 4-week trial of conservative therapy has not improved symptoms, or symptoms have worsened during conservative therapy:**

a. tarsal coalition
b. sinus tarsi syndrome
c. CRPS d. plantar fasciitis e. bursitis/tendinitis
f. ankle sprain (not high in anatomy)
g. Baker’s cyst h. femoroacetabular impingement i. suspected hip or shoulder labral tear
j. sports hernia k. epicondylitis of the elbow (medial or lateral) l. adhesive capsulitis

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MRI will be considered medically necessary for each of the conditions Q. a-l, if a 4- week trial of conservative therapy has not improved symptoms, or symptoms have worsened during conservative therapy.** However, for femoroacetabular impingement and suspected labral tears, as per O. and P. (above) if physical exam findings corroborate clinical suspicions, a trial of conservative therapy is not required.

Contrast-enhanced MRI of the MSK (musculoskeletal) system is medically necessary if ONE of the following are met:

a. MRI arthrography (non-contrast images not required) b. inflammatory arthritis such as rheumatoid arthritis
c. suspected tumors or infection (soft tissue or bone/osteomyelitis), in which case both noncontrast and contrast images are medically necessary.

**For purposes of the medical policy, a trial of conservative treatment is defined as a combination of both active and inactive components, dedicated to the area of interest during the current episode of pain or within the past six months. Inactive components include medications (such as analgesics, anti-inflammatory medications, muscle relaxants), rest, ice, heat, or injections/acupuncture. Active modalities include either Physical Therapy, Chiropractic or osteopathic manipulations, or a physician assisted home exercise program.

Requests for repeat MR imaging, after completing MR of the same anatomic site in the past 6 months, will be reviewed on a case-by-case basis. The most recent imaging reports must be submitted, and for the repeat exam to be approved as medically necessary, ONE of the following MUST be met:

a) documentation that the prior testing was inconclusive, or with short-term follow-up imaging recommended. b) clinical documentation of progressive worsening of symptoms or new physical exam findings prompting the repeat imaging, and that patient management will be altered by the imaging results.
c) interval surgery (with suspected complication) or significant new trauma to that anatomic region.

Limitations of Coverage:

A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. The following indications are considered not medically necessary for MRI:

a. sebaceous cysts
b. subcutaneous lipoma, unless surgery planned or malignant degeneration suspected.

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c. ganglion, except as noted in Indications of Coverage (above) d. Serial MRI to assess healing or recovery from disease is not medically necessary, with rare exceptions (medical director review is needed). e. Repeating an MRI before 3 months after an initial MRI showing stress fracture/stress reaction.

C. The following indications are considered experimental, investigational, unproven:

a. MRI for evaluation of compartment syndrome is experimental, investigational, unproven (direct measurement of compartment pressures is standard of care).
b. Dynamic or positional MRI (to include weight-bearing or kinetic MRI). c. Low field MRI for musculoskeletal conditions.

D. Pre-operative MRI for surgical planning using intraoperative navigation for joint arthroplasty is deemed not medically necessary, as computer-assisted surgical navigation is deemed experimental, investigational, unproven.

E. For 3D Rendering of MRI, please refer to the WPS medical policy, 3D rendering for MRI, CT, and Ultrasound.

Documentation Required:

Prior authorization is required for all upper and lower extremity MRI procedures. To obtain prior authorization, the requesting provider must submit the following information:

• The patient's medical history and physical examination findings • The specific indication for upper/lower extremity MRI • The results of any other relevant tests

Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com.

Page 9 of 9

Policy Review History:

Implemented 01/01/2024 Medical Policy Committee Approval 10/26/2023 Reviewed

10/26/2023 Revised 02/23/2024 effective 04/23/2024 Developed 10/26/2023

Approved by the Medical Director