MRI (Magnetic Resonance Imaging) of the Neck, Face, Orbit Form

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MRI (Magnetic Resonance Imaging) of the Neck, Face, Orbit Medical Guideline

Service: MRI of the Neck, Face, Orbit

PUM 250-0055-1812

Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026

Description: MRI of the neck, face, orbit is used to evaluate infection, trauma, and masses. It is used for therapy planning and follow-up of face and neck neoplasms. Also, can be used for vocal cord lesions, neck lymphadenopathy, and abnormalities of the external eye and nose.

Indications of Coverage:

MRI of the Neck, Orbit, or Face is considered medically necessary when at least ONE of the following indications are met:

A. Evaluation or Staging of Neoplasm/Cancer with ONE of the following:

i. Head and neck cancer and at least ONE of the following:

a. initial tumor staging
b. to monitor treatment response
c. with signs or symptoms suggesting recurrent disease
d. annual surveillance, post treatment, of areas unable to be clinically examined.

ii. cancer presenting as neck mass, without primary site identified.

iii. initial staging of extra nodal lymphoma, Hodgkin lymphoma, known or suspected parathyroid cancer.

iv. for persisting symptoms suggestive of tumor, despite negative clinical exam.

v. thyroid enlargement or nodule, and need to assess cervical lymph nodes, substernal extent, or tracheal compression.

vi. thyroid cancer with one of the following:

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a. newly diagnosed and initial staging needed.
b. post operative evaluation with gross residual disease OR medullary thyroid cancer and calcitonin level greater than 150 mg/mL at least 8 weeks after surgery.

c. suspected tumor recurrence, with BOTH unexplained thyroglobulin level AND negative or indeterminate whole-body iodine 131 scan and neck ultrasound.

B. Suspected tumor or cancer with ONE of the following:

i. suspicious lesion(s) of mouth/throat

ii. mass or abnormality or unexplained adenopathy found on endoscopy, physical exam or CT/Ultrasound, and further characterization needed.

iii. parotid mass with ultrasound and/or CT being indeterminate or needing further characterization.

C. Persistent anosmia (loss of smell) or dysosmia (change in sense of smell) of unknown origin, documented with objective testing (includes congenital anosmia/dysosmia).

D. Evaluation of congenital anomalies

E. Evaluation of unexplained, recurrent epistaxis, with negative initial evaluation (such as coagulation studies, nasal exam).

F. Abnormality of external eye, or noted on direct exam, including one of the following:

i. exophthalmos or enophthalmos

ii. optic disc swelling/edema (for unilateral, approve MRI orbit, for bilateral, approve MRI orbit and brain).

iii. suspicion of orbital infection/cellulitis

iv. unexplained visual field defect or diplopia

v. suspected or known ocular mass/tumor, to include retinoblastoma.

vi. orbital trauma with direct eye injury

vii. optic neuritis/neuropathy

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viii. abnormally limited eye movement or suspected orbital pseudotumor.

ix. congenital orbital anomalies, including pediatric orbital asymmetry.

x. nystagmus in patient older than 6 months

xi. child with slowly progressive visual loss

xii. adult with visual loss combined with uveitis or scleritis.

G. Known or suspected fetal head/neck abnormality, and MRI results needed to help direct management.

H. Suspected or known Graves orbitopathy and ONE of the following:

i. need to monitor response to treatment.

ii. with unexplained decline in visual acuity in a patient with hyperthyroidism.

iii. to direct whether surgical or immunosuppressive treatment is more optimal.

I. For spontaneous CSF rhinorrhea/leak when CT scan is indeterminate, contraindicated or unavailable.

J. For evaluation of rhinosinusitis, with clinical suspicion of ONE of the following:

i. fungal infection

ii. osteomyelitis

iii. cavernous sinus thrombosis

iv. pre-septal/orbital infection

v. central nervous system infection (cranial neuropathy)

K. For evaluation of temporomandibular joint (TMJ), with clinical suspicion of ONE of the following:

i. Trauma to TMJ with need for assessment of meniscal position and integrity; AND Plain X-ray or CT scan results indeterminate.

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ii. Preoperative or postoperative planning
iii. Pain in TMJ (moderate to severe) with BOTH of the following criteria met: a. Pain worsens with chewing, talking (using jaw) b. Completed 4 weeks or more of conservative treatment (medications, physical therapy, etc.) iv. Cancer or neoplasm of TMJ v. Inflammatory arthropathy indicated by ANY of the following: a. rheumatoid arthritis b. psoriatic arthritis c. juvenile idiopathic arthritis d. ankylosing spondylitis.

L. For evaluation of infection, with suspected retropharyngeal abscess or suspected osteomyelitis or abscess of the face/orbit/neck and CT/Ultrasound is indeterminate, or further characterization is required after initial CT/Ultrasound.

M. For evaluation of trauma to the neck/orbit/face, and CT/Ultrasound is indeterminate, or further characterization is required after initial CT/Ultrasound.

N. For evaluation of unexplained trigeminal neuralgia or for evaluation of objective palsy of cranial nerves 9, 10, 11, or 12.

O. Sinonasal obstruction with underlying mass seen on endoscopy/exam or prior imaging.

P. For evaluation of vocal cord lesions or vocal cord paralysis.

Q. For presurgical planning of diagnosed primary hyperparathyroidism, with further characterization needed after ultrasound and/or nuclear medicine exams, OR prior to repeat surgery for hyperparathyroidism.

R. MRI of the Internal Auditory Canal is medically necessary when ONE of the following is met:

i. Pulsatile tinnitus or unilateral tinnitus

ii. asymmetric sensorineural hearing loss or suspected acoustic
neuroma/Schwannoma.

iii. preoperative planning for cochlear implant

iv. CSF otorrhea (for intermittent leaks), for active leaks, only when CT is contraindicated or not available or CT results are indeterminate.

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v. congenital/childhood sensorineural hearing loss

vi. For evaluation of cholesteatoma, only if CT is indeterminate, contraindicated, or unavailable.

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:

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. For evaluation of suspected infectious/inflammatory adenopathy, MRI is considered not medically necessary unless there is a documented failure of a two-week trial of treatment.

Documentation Required:

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

• 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.

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• 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, 06/01/24, 09/01/25, 05/01/26 Medical Guideline Committee Approval 10/26/23, 05/30/24, 03/27/25, Q1 2026 Reviewed

10/26/23, 05/30/24, 03/27/25, Q1 2026 Developed 10/26/23

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

70336 Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s)
70540 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)
70542 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; with contrast material(s)
70543 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences

ASSOCIATED CODES A9573 Injection, Gadopiclenol, 1 mg
A9575 Injection, Gadoterate Meglumine, 0.1 ml
A9577 Injection, Gadobenate Dimeglumine (Multihance), per ml
A9585 Injection, Gadobutrol, 0.1 ml