LCD L34425

Coverage Guidance

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220.2 Magnetic Resonance Imaging (MRI)

Indications and Limitations of Coverage

Magnetic resonance imaging (MRI) is a radiation-free, noninvasive technique used to produce high-quality sectional images of the inside of the body in multiple planes. MRI uses natural magnetic properties of the hydrogen atoms in the body that emit radiofrequency signals when exposed to radio waves within a strong magnetic field. These signals are processed and converted by a computer into high-resolution, three-dimensional, tomographic images. Images and resolution produced by MRI is quite detailed. For some MRI, contrast materials (e.g., gadolinium, gadoteridol, non-ionic and low-osmolar contrast media, ionic and high-osmolar contrast media) are used to enable visualization of a body system or body structure.1

MRI provides superior tissue contrast when compared to a computerized tomography (CT) scan, can image in multiple planes, is not affected by bone artifact, provides vascular imaging capability, and makes use of safer contrast media (gadolinium chelate agents).1 Its major disadvantage over a CT scan is the longer scanning time required for study, making it less useful for emergency evaluations. Contraindications include patients with implanted neurostimulators or cochlear implants. Potential contraindications may include patients with cardiac pacemakers (refer to the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220.2), metal fragments in the eye, magnetic ocular implants or patients with older ferromagnetic intracranial aneurysm clips. All these objects may be potentially displaced when exposed to the powerful magnetic fields used in MRI.

MRI of the orbit, face and/or neck may be considered medically reasonable and necessary when used to diagnose and characterize pathology of the eye, nasopharynx, oropharynx, and neck including tumors, infection, soft tissue pathologies, and congenital abnormalities. In cases involving trauma to the orbit, face and/or neck, a CT scan is frequently superior to MRI for assessing injury.

In many instances, ordering an MRI of the brain, in addition to an MRI of the orbit, face and/or neck, may be medically necessary on the same day. The medical record should document the medical necessity for these 2 procedures being performed on the same day.

Summary of Evidence

A literature review was conducted to highlight some of the areas where MRI of the orbit, face and neck was used to demonstrate the utility of this imaging modality. Sources include published peer-reviewed articles and published society guidelines from the last 25 years.

MRI is superior for the evaluation of the visual pathways, globe and soft tissues; CT is preferred for visualizing bony detail and calcifications.2,3

Orbital MRI may be used for abnormalities detected on external or direct eye examinations, optic neuritis, orbital trauma, ocular mass(es), known or suspected orbital infection, osteomyelitis, congenital anomalies and strabismus concerns.4-25

Sinus MRI may be required to detect abnormalities and conditions such as rhinosinusitis with suspicion of fungal infections, clinical suspicion of orbital or intracranial complications, suspected mass based upon exam, nasal endoscopy or previous imaging and for conditions such as anosmia or osteomyelitis.20,21,26-31

Various facial masses, facial trauma, autoimmune diseases and neuropathies, such as trigeminal neuralgia, may be diagnosed or evaluated further with MRI imaging.18,19,26,27,33-39

In addition, neck MRI may be useful for the management of conditions involving the neck, including lesions involving the mouth, throat or neck; suspicious masses/tumors found on another imaging modality that needs additional clarification; neck masses or lymphadenopathy; infections of the face, neck or neck spaces involving any of the fascial planes; neurological conditions such as Bell’s palsy, hemifacial spasm or other neuropathies; and suspected thyroid or parathyroid neoplasms. Other neck indications could include evaluation of the salivary glands, vocal cords, and internal auditory canals and middle ear.12,29,34,40-55

Analysis of Evidence

MRI is reasonable and necessary in the evaluation of medical and surgical conditions involving the orbit, face and neck region; such conditions may include but are not limited to congenital and inherited diseases, neoplasms, trauma, and infection. The soft tissue contrast between normal and abnormal tissues provided by MRI is sensitive for differentiating between inflammatory disease and malignant tumors and permits the precise delineation of tumor margins. MRI is useful for therapy planning and follow-up of face and neck neoplasms. It is also used for the evaluation of neck lymphadenopathy and vocal cord lesions.

CT scanning remains the study of choice for the imaging evaluation of acute and chronic inflammatory diseases of the sinonasal cavities. MRI is not considered the first-line study for routine sinus imaging because of limitations in the definition of the bony anatomy and length of imaging time. MRI for confirmation of diagnosis of sinusitis is discouraged because of hypersensitivity (overdiagnosis) in comparison to CT without contrast. MRI, however, is superior to CT in differentiating inflammatory conditions from neoplastic processes. MRI may better depict intraorbital and intracranial complications in cases of aggressive sinus infection, as well as differentiating soft-tissue masses from inflammatory mucosal disease. MRI may also identify fungal invasive sinusitis or encephaloceles.

Therefore, based upon an extensive review of the literature, MRI of the orbit, face and neck is reasonable and necessary for the diagnosis of various medical and surgical conditions of the head and neck region and the sinuses, when medically indicated.

Associated Information

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B MAC upon request.

Utilization Guidelines

In general, it is not medically necessary to perform myelography, CT examinations, and MRI examinations for evaluation of the same condition on the same day. The medical record should document the necessity for evaluations in addition to an MRI scan.

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Bibliography

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