MRI (Magnetic Resonance Imaging) of the Head/Brain Form

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

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

PUM 250-0060-1812

Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026 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 (activities of daily living) EXCEPT for typical migraine with a normal neurologic exam, with or without aura. ii. Chronic headache with a change in frequency, severity, or duration).

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iii. Cluster headaches or other trigeminal-autonomic cephalgia’s, including paroxysmal hemicrania, hemicrania continua, short- lasting unilateral neuralgiform headache attacks.
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. Immunocompromised state
8. Pregnancy to include puerperium
9. Subacute head trauma
10. Severe unilateral headache with radiation to or from the neck, associated with suspicion of carotid or vertebral artery dissection.
11. Progressively worsening.
12. New onset of headache and age at least 50 years old.
13. 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:
14. Occipital headache
15. Age <6 years
16. Symptoms indicative of increased intracranial pressure, such as recurring headaches after waking.
17. Underlying disease that predisposes to intracranial pathology, including, but not limited to immune deficiency,

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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.

2. Known or suspected seizure disorders: a. Initial assessment of patients with a first unprovoked seizure 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, and EITHER of the following:
   • Change in seizure pattern. • Status epilepticus c. Seizures refractory to medical management.

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

4. Known or suspected tumors with any of the following: a. Detection and characterization of intracranial neoplasms with one or more of the following:
   i. Acute, new, or fluctuating neurologic symptoms including, but not limited to changes in mental status, or motor, sensory, speech or

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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.
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. Meningioma (benign, atypical, or unresected) managed by observation only at 3, 6, and 12 months, then every 6 months for 5 years, then every 1 to 3 years as clinically indicated. g. Screening for non-CNS Cancers and Hereditary Cancer Syndromes in accordance with NCCN guidelines. h. Screening in the following known conditions:
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). i. Follow up of known Rathke cleft cyst

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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. j. Follow-up of known arachnoid cyst
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. k. 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. l. Midline dermoid cysts/sinuses with concern for intracranial extension. m. 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.
   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, paresthesia’s (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; 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.
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

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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 also, with one follow-up at 6-12 months. 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).
d. New neurologic signs or symptoms with concern for progression of disease. e. Prior to starting or changing 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. One time evaluation for Cognitive impairment of unknown etiology, memory loss, or changes in mental status including unexpected changes in existing symptoms or clinical course. b. For evaluation of suspected Parkinson’s with atypical features or unresponsive to levodopa. c. For evaluation of new non-Parkinson neurological symptoms in known Parkinson’s disease complicating the evaluation of the current condition. d. For the evaluation of other movement disorder to exclude a structural lesion (i.e., suspected Huntington disease, chorea, atypical parkinsonian syndromes, hemiballismus, atypical dystonia).

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e. MRI-Guided focused ultrasound surgery when ALL of the following are present: i. Diagnosis of essential tremor ii. Failure of, intolerance to, or contraindication to 2 or more medication treatments for essential tremor (e.g., propranolol, primidone, carbamazepine, gabapentin iii. Tremor interferes with daily activities iv. Unilateral treatment planned

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. Significant delay or failure to reach milestones in at least two of the following developmental domains: a. Gross/fine motor control b. Speech/language c. Cognition d. Social/personal e. Activities of daily living **One time scanning of a child with cerebral palsy is considered medically necessary.
13. 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)]
    d. Central hyperthyroidism (high TSH)

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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
h. Surveillance of pituitary incidentaloma; intervals include one of the following: i. For macroincidentaloma: 6 months after initial scan, then annually for next 3 years if stable in size, and less often thereafter ii. For microincidentaloma: 1 year after initial scan, then every 1 to 2 years for next 3 years if stable in size, and less often thereafter.

14. 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: i. Papilledema ii. Nystagmus iii. Optic atrophy 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: i. Atypical presentation ii. >3 weeks slow resolution iii. No improvement at 4 months iv. Facial twitch or spasms at onset

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f. Cranial nerve palsy g. Anosmia/hyposmia (not explained by COVID or other known etiologies)

15. Evaluation of suspected or known acoustic neuroma
16. 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.
17. Diagnosis and follow up of known or suspected neurosarcoidosis
18. Pre-operative and post-operative imaging for neurosurgical procedures
19. Evaluation of suspected or known inner ear disorders
20. Further evaluation when needed based on CT or x-ray imaging or cranial ultrasound.
21. Brief Resolved Unexplained Event (BRUE/ALTE) in an infant when history or exam are concerning for a neurologic cause.
22. For Functional Brain MRI for pre-surgical planning in ONE of the following scenarios: a. To identify the eloquent cortex in pre-surgical evaluation of patient’s with brain tumors (except temporal tumors) b. Epilepsy (except temporal neocortical epilepsy) c. Vascular malformations
23. Vertigo or Dizziness when ONE of the following scenarios is met: a. When associated with additional signs or symptoms suggestive of a central nervous system lesion b. Tullio’s phenomenon (noise-induced dizziness) c. Symptoms associated with abnormal audiogram or vestibular function testing suggestive of an intracranial or vestibulocochlear mass lesion. **Note: Vertigo or dizziness that is clearly related to positional change does not require advanced imaging.
24. Unless addressed under other “Indications of Coverage” above, if there is a request for repeat MRI of the brain within 6 months of similar imaging, there must be EITHER: a. Documentation that the prior test was inconclusive, or short-term follow- up imaging was needed; OR

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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; OR c. Interval surgery (with suspected complication) or significant new trauma to that anatomic region.
Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.” 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 considered 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 considered not medically necessary.

D. Head and brain MRI is considered 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:

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• A standard written order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis. • Medical record information (including continued need/use if applicable) and medical necessity. • Correct coding for the service that meets all coding guidelines.

Disclaimer: This guideline 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 guideline. 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 guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical guidelines 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 guideline 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. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered. State mandates, laws or benchmark supersede this medical guideline.

Imaging is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

**All imaging related to cancer care, WPS uses NCCN as a primary reference.

Guideline Review History:

Implemented 01/01/24, 12/01/24, 09/01/25, 05/01/26 Medical Guideline Committee Approval 11/30/23, 11/21/24, 03/27/25, Q1 2026 Reviewed

11/30/23, 11/21/24, 03/27/25, Q1 2026 Revised 02/23/24 effective 04/23/24 Developed 11/30/23

Approved by the Medical Director

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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Codes
Code Description

61715 Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed
70551 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material
70552 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); with contrast material(s)
70553 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences
70554 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration
70555 Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing
96020 Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (i.e., psychologist), with review of test results and report
0865T Quantitative magnetic resonance imaging (MRI) analysis of the brain with comparison to prior magnetic resonance (MR) study(ies), including lesion identification, characterization, and quantification, with brain volume(s) quantification and/or severity score, when performed; data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the brain during the same session
0866T Quantitative magnetic resonance imaging (MRI) analysis of the brain with comparison to prior magnetic resonance (MR) study(ies), including lesion detection, characterization, and quantification, with brain volume(s) quantification and/or severity score, when performed, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the brain (list separately in addition to code for primary procedure)
0947T Magnetic resonance imaging guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, including stereotactic navigation and frame placement, when performed

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ASSOCIATED CODES 70557 Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or residual vascular malformation); without contrast material
70558 Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or residual vascular malformation); with contrast material(s)
70559 Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or residual vascular malformation); without contrast material(s) and further sequences
A9503 Technetium TC-99M Medronate, diagnostic, per study dose, up to 30 millicuries
A9573 Injection, Gadopiclenol, 1 ml
A9575 Injection, Gadoterate Meglumine, 0.1 ml
A9576 Injection, Gadoteridol, (Prohance multipack), per ml
A9577 Injection, Gadobenate Dimeglumine (Multihance), per ml
A9579 Injection, Gadolimium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml
A9585 Injection, Gadobutrol, 01. ml
Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml
Q9969 TC-99M from non-highly enriched uranium source, full cost recovery add-on, per study dose