Magnetic resonance imaging (MRI) is a diagnostic imaging modality that uses magnetic and radiofrequency fields to produce a non-invasive two-dimensional view of an internal organ or structure. Through radiofrequency emissions, a tomographic image can be constructed that will represent the tissue being analyzed and the environment surrounding it. The MRI is designed to identify anatomical abnormalities and to provide information on the characteristics of the tissue.

The criteria for determining medical necessity for MRI is as follows and may be warranted when indicated by physical exam and/or diagnostic studies (i.e., CT scan, X-ray, etc.), or when symptoms are unresolved by conservative treatment:

Head (Brain), Orbit, Face, Neck, Spine (Cervical, Thoracic, Lumbar):

• Suspected, but undiagnosed, hemorrhage or non- hemorrhagic infarct;
• Suspected tumor;
• Initial staging of metastases and/or known brain metastasis with new or worsening symptoms and results of MRI will alter management;
• Evaluation of developmental anomalies;
• Postoperative study within 48 hours;
• Evaluation of obstruction, masses, trauma and suspected anatomical abnormalities;
• Suspected abscess; suspected multiple sclerosis, or spinal cord of bone marrow disease;
• Suspected cervical or thoracic cord injury, or lumbar neurologic injury with neurologic deficit; or
• Suspected cerebral aneurysm expansion, impending rupture, rupture or aneurysmal leak.

Cardiac:

• MRI may be considered medically necessary when echocardiography or CT are non-diagnostic and fail to resolve the clinical question.
• Suspected right ventricular arrythmogenic dysplasia, a structurally abnormal right ventricle, usually diagnosed because of a symptomatic arrhythmic event (e.g., syncope) and one of the following:
• Mild right ventricular enlargement by two- dimensional echocardiography trans thoracic echo (TTE);
• Regional right ventricular systolic dysfunction by two-dimensional echocardiography trans thoracic echo (TTE); or
• Sustained (greater than 30 seconds) ventricular tachycardia by EKG, Holter, or trans thoracic echo (TTE).
• Suspected constrictive pericarditis identified with non-diagnostic TTE or TEE;
• Suspected intracardiac mass identified with TTE or TEE; d. Velocity flow mapping:
• Evaluate and measure the velocity of blood flow in pulmonary arteries, aorta and superior and inferior vena cava of the heart and to measure pulmonary regurgitation after congenital cardiac surgery:
• In patients who are not adequately evaluated by ultrasound and trans thoracic echo (TTE) or
• In patients who are not candidates for trans thoracic echo (TTE) or
• When other techniques such as echocardiography and CT are indeterminate.

Chest:

• Staging of lung cancer when one of the following is suspected:
• Aorta or vena cava invasion with a centrally located mass by CT scan, or
• Suspected cord involvement with posterior tumor by CT scan or posterior mediastinal mass on chest x-ray;
• Differential diagnosis of pulmonary arteries from hilar masses in patients allergic to IV contrast or hilar enlargement by chest x-ray with non-diagnostic CT scan;
• Suspected abnormalities of the aorta or aortic arch (e.g., thoracic aortic dissection, thoracic/thoracoabdominal aneurysm);
• Suspected neural tumors of the mediastinum;
• Paracardiac mass or suspected paracardiac mass by echocardiogram or CT scan. Common paracardiac masses include pericardial cysts, an enlarged pericardial fat pad, lymphoma, adjacent malignant tumor, teratoma, thymoma, and diaphragmatic hernia; or
• Suspected thymoma (neoplastic enlargement of the thymus gland) in patients with myasthenia gravis.

Extremities:

• Whole-body, circumferential or open MRI has been medically proven to be effective and therefore medically appropriate for:
• Extremities (bone and soft tissue)—ankles, hips, knees, shoulders, elbows, wrists:
• Suspected or known tumor of bone or soft tissue, palpable mass of extremity and x-ray non-diagnostic;
• Staging of known bone or soft tissue malignancy;
• Suspected bone tumor with cancer elsewhere;
• Follow-up to a single metastasis or primary bone tumor after treatment;
• Suspected stress fracture or bony injuries;
• Preoperative evaluation of osteomyelitis or suspected osteomyelitis;
• Suspected avascular necrosis;
• Suspected joint space infection;
• Suspected tendon disruptions;
• Suspected intra-articular loose bodies, chondromalacia, or chondral defects;
• Suspected impingement syndromes or ligament tears;
• Recurrent dislocation; or
• Suspected meniscal injuries.

Dedicated, extremity MRI has been medically proven to be effective and therefore medically appropriate for the conditions noted below, when performed on the knee, shoulder, elbow, wrist, foot or ankle:

• Suspected stress fracture or bony injuries;
• Suspected tendon disruptions;
• Suspected intra-articular loose bodies, chondromalacia, or chondral defects;
• Suspected impingement syndromes or ligaments tears; 
• Recurrent dislocation; or
• Suspected meniscal injuries

Abdomen:

• Suspected aneurysm expansion, impending rupture, rupture or aneurysmal leak;
• Suspected abdominal tumor;
• Suspected abdominal abscess; or
• Evaluation of possible abdominal hemangioma.

Pelvis

• Staging of known carcinoma of the bladder, cervix, endometrium, ovary, prostate, seminal vesicle or rectum;
• Evaluation of treatment response for an established diagnosis of endometriosis;
• Suspected pelvic abscess;
• Suspected pelvic tumor; or
• Evaluation of possible pelvic hemangioma.

Miscellaneous:

•  Temporomandibular joint:
  • Suspected internal derangement of temporomandibular joint, or
  • Evaluation of temporomandibular joint dysfunction when symptoms include continued pain, limitation of motion, and tenderness at the joint.
• Bone marrow blood supply:
• Evaluation of bone marrow in patients with aplastic anemia, which allows for quantitative and noninvasive assessment of water content in bone marrow before and after treatment avoiding repeated biopsy in patients with neutropenia and thrombocytopenia; or
• Evaluation of bone marrow infiltration and activity in Gaucher patients to assess response to enzyme replacement therapy.

The following are contraindications to any type of MRI:

1. Pregnancy, first trimester; or
2. Patients in whom MRI is not applicable because of severity of illness; or
3. Implanted devices that are electrically or magnetically activated (e.g., cardiac pacemakers, drug infusion pumps); or
4. Ferromagnetic metal objects (e.g., cerebral aneurysm clips).

When a contrast-enhanced magnetic resonance imaging (MRI) study is performed on the same day as an unenhanced study of the same organ or body area, the appropriate combination code should be used.

Example: MRI, brain; without contrast material (70551) followed by MRI, brain; with contrast material (70552) - use combination code 70553.

Payment is made for contrast material in addition to the MRI procedure. The diagnostic imaging agent/contrast material used in conjunction with an eligible imaging procedure is eligible when administered by the health care professional in a setting other than a hospital or a skilled facility.

When charges for additional acquisitions, cuts, slices, etc., are billed separately, the charges are combined and paid under the appropriate code for the study performed.

MRI studies of the following body areas are eligible for payment:

70336 - temporomandibular joint
70540, 70542, 70543 - orbit, face, and neck
70551, 70552, 70553, 70557, 70558, 70559 - brain including the brain stem
71550, 71551, 71552 - chest
72141, 72142, 72156 - cervical spine
72146, 72147, 72157 - thoracic spine
72148, 72149, 72158 - lumbar spine
72195, 72196, 72197 - pelvis
73218, 73219, 73220 - upper extremity, other than joint
73221, 73222, 73223 - any joint, upper extremity
73718, 73719, 73720 - lower extremity, other than joints
73721, 73722, 73723 - any joint, lower extremity
74181, 74182, 74183 - abdomen
75557, 75559, 75561, 75563 - cardiac
76400 - bone marrow

When more than one organ in an anatomic area is studied on the same day (for example, liver and gallbladder), payment is limited to one MRI study of that anatomic area.

If more than one anatomic area is studied (for example, the brain and abdomen), payment is made for each anatomic area studied.

When bilateral studies of the temporomandibular joint (TMJ) are reported, payment is made for each study.

When bilateral extremity studies are performed (for example, right and left arms or right and left legs) payment is made for each study.

When different areas of the same extremity are performed (for example, left humerus and left forearm or right knee and right ankle, etc.), payment is made for both studies.

All other studies are reimbursed as one study. In all cases, clinical information documenting the medical necessity for each MRI study on the same day must be maintained in the patient’s record and available for review upon request.

When both MRI and a computed tomography (CT) scan are performed on the same day for the same anatomic area, payment should be made for the CT scan. The MRI may only be paid if supporting documentation is submitted to establish medical necessity for both studies.

Cardiac magnetic resonance imaging for flow velocity/quantification (codes 75558, 75560, 75562, 75564) is considered experimental/investigational. Scientific evidence does not demonstrate the efficacy of cardiac MRI for velocity flow mapping. As such, it is not eligible for payment. A participating, preferred, or network provider can bill the member for services denied as experimental/investigational.

Date Last Reviewed:  11/2006

Description

Magnetic resonance imaging, also referred to as nuclear magnetic resonance (NMR), is a noninvasive diagnostic imaging modality. The technique uses the interaction of a magnetic field and radiofrequency waves to generate, with computer assistance, an image of an area of the body.

For information on MRI of the breast see Medical Policy Bulletin X-44.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical Policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.