GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy
IINDICATIONS FOR BONE MARROW MRI
Hematologic Malignancies

• Bone Marrow MRI is indicated for the evaluation of the following conditions:
  • Multiple Myeloma - monoclonal proliferation of plasma cells with myeloma-defining CRAB (Calcium level elevation, Renal failure, Anemia, or Bone lesions) findings
  • Monoclonal Gammopathy of Undetermined Significance (MGUS) ⁠— monoclonal proliferation of plasma cells without myeloma-defining CRAB
  • Solitary Plasmacytoma - monoclonal plasma cells manifesting as a single tumor
  • Smoldering Multiple Myeloma ⁠— monoclonal proliferation of plasma cells in bone marrow and/or serum/urine with abnormal levels of monoclonal protein (asymptomatic precursor state of MM)¹
  • Leukemia and other related hematological malignancies^2,3,4
• Bone Marrow MRI for the above conditions is indicated at the following intervals:
  • Suspected Disease
  • Initial Staging of Known Disease
  • Restaging on Active Treatment
  • Surveillance 
    • Annually if in asymptomatic
    • More frequent imaging as clinically indicated by signs/symptoms, laboratory, or radiographic concern for disease relapse or progression

Bone Marrow MRI using CPT 77084 is used for evaluation of the bone marrow. For conditions where imaging of the soft tissue and bone is needed (such as screening for genetic predisposition syndromes such as Li-Fraumeni syndrome (LFS) with whole body MRI using CPT 76498), see indications for Whole Body MRI.

Bone Marrow Disorders

• Diagnosis and assessment of treatment response in diffuse or multifocal marrow disorders (e.g., chronic recurrent multifocal osteomyelitis; marrow involvement in storage diseases, such as Gaucher’s, or hematologic malignancies/ processes (e.g., Waldenström macroglobulinemia) when the diagnosis is in doubt)^3,5,e

Rationale
MMRI
Magnetic Resonance Imaging (MRI) is currently used for the detection of disease in the bone marrow. Bone marrow MRI is primarily used for detection of tumor in the bone marrow (metastatic or primary) or for disorders of the bone marrow. The study covers from the top of the skull to the heels.

Contraindications and Preferred Studies

• Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester)
• Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non-compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine.s.⁵

References

1. Mateos M, Kumar S, Dimopoulos M, González-Calle V, Kastritis E et al. International Myeloma Working Group risk stratification model for smoldering multiple myeloma (SMM). Blood Cancer Journal. 2020; 10: 10.1038/s41408-020-00366-3. 
2. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) NCCN Guidelines Index Table of Contents Discussion Multiple Myeloma Version 2.2024. National Comprehensive Cancer Network®. 2023; https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf. 
3. Rajkumar V, Dimopoulos M, Palumbo A, Blade J, Merlini G et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. The Lancet Oncology. 2014; 538-548. 10.1016/S1470-2045(14)70442-5. 
4. Rodríguez-Laval V, Lumbreras-Fernández B, Aguado-Bueno B, Gómez-León N. Imaging of Multiple Myeloma: Present and Future. J Clin Med. 2024; 13: J Clin Med. 
5. Degnan A, Ho-Fung V, Ahrens-Nicklas R, Barrera C, Serai S et al. Imaging of non-neuronopathic Gaucher disease: recent advances in quantitative imaging and comprehensive assessment of disease involvement. Insights into imaging. 2019; 10: 70. 10.1186/s13244-019-0743-5.

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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