Description 

Magnetic resonance imaging (MRI) is used in the evaluation of face and neck region masses, 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 used 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.

Anosmia — Nonstructural causes of anosmia include post viral symptoms, medications (Amitriptyline, Enalapril, Nifedipine, Propranolol, Penicillamine, Sumatriptan, Cisplatin, Trifluoperazine, Propylthiouracil). These should be considered prior to advanced imaging to look for a structural cause. Anosmia and dysgeusia have been reported as common early symptoms in patients with COVID-19, occurring in greater than 80 percent of patients. For isolated anosmia, imaging is typically not needed once the diagnosis of COVID has been made given the high association. As such, COVID testing should be done prior to imaging.^66,67,68

MRI orbits, face, and neck MRI rather than MRI brain is the mainstay for directly imaging the olfactory apparatus and sinonasal or anterior cranial fossa tumors that may impair or directly involve the olfactory apparatus.³³

CSF (cerebrospinal fluid) leaks — For CSF rhinorrhea, Sinus CT is indicated when looking to characterize a bony defect. For CSF otorrhea, temporal bone CT is indicated. For intermittent leaks and complex cases, consider CT/MRI/nuclear cisternography. There should be a high suspicion or confirmatory CSF fluid laboratory testing (Beta-2 transferrin assay).^69,70

Trigeminal Neuralgia — According to the International Headache Society, TN is defined as “a disorder characterized by recurrent unilateral brief electric shock-like pain, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve and triggered by innocuous stimuli.”⁷¹

General Information
IIt 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.

Purpose
Magnetic resonance imaging (MRI) is used in the evaluation of orbit, face and neck region masses, 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 used 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.

Special Note
If there is a combination request* for an overlapping body part, either requested at the same time or sequentially (within the past 3 months) the results of the prior study should be:

• Inconclusive or show a need for additional or follow up imaging evaluation OR
• The office notes should clearly document an indication why overlapping imaging is needed and how it will change management for the patient.

(*Unless approvable in the combination section as noted in the guidelines).

Policy 
ORBIT MRI is considered MEDICALLY NECESSARY for the following indications: 

IINDICATIONS FOR ORBIT MRI
MRI is superior for the evaluation of the visual pathways, globe and soft tissues; CT is preferred for visualizing bony detail and calcifications (1,2)

Orbit MRI

• Abnormal external or direct eye exam
  • Exophthalmos (proptosis) or enophthalmos
  • Ophthalmoplegia with concern for orbital pathology
  • Unilateral optic disk swelling (3,4,5)
  • Documented visual field defect (6,7,8)
    • Unilateral or with abnormal optic disc(s) (e.g., optic disc blurring, edema, or pallor); AND
    • Not explained by underlying diagnosis, glaucoma, or macular degeneration
• Optic neuritis (9,10)
  • If atypical presentation (bilateral, absence of pain, optic nerve hemorrhages, severe visual impairment, lack of response to steroids, poor recovery or recurrence) (11,12)
  • If needed to confirm optic neuritis and rule out compressive lesions
• Orbital trauma (13,14)
  • Physical findings of direct eye injury
  • Suspected orbital trauma with indeterminate x-ray or ultrasound
• Orbital or ocular mass/tumor, suspected or known (1,15)
• Clinical suspicion of orbital infection (1,2)
• Clinical suspicion of osteomyelitis (16,17)
  • Direct visualization of bony deformity OR
  • Abnormal x-rays
• Clinical suspicion of Orbital Inflammatory Disease (e.g., eye pain and restricted eye movement with suspected orbital pseudotumor) (18)
• Congenital orbital anomalies
• Complex strabismus syndromes (with ophthalmoplegia or ophthalmoparesis) to aid in diagnosis, treatment and/or surgical planning (19,20,21)

NOTE: ADDITIONAL ONCOLOGIC ORBIT MRI INDICATIONS

Indications for Combination Studies
Orbit/Brain MRI Combination Studies

• Optic neuropathy or unilateral optic disk swelling of unclear etiology to distinguish between a compressive lesion of the optic nerve, optic neuritis, ischemic optic neuropathy (arteritic or non-arteritic), central retinal vein occlusion or optic nerve infiltrative disorders (22)
• Bilateral optic disk swelling (papilledema) with vision loss (5)
• Optic neuritis
  • If atypical presentation (bilateral, absence of pain, optic nerve hemorrhages, severe visual impairment, lack of response to steroids, poor recovery or recurrence)(9,10,11,12,23,24)
  • If needed to confirm optic neuritis and rule out compressive lesions
• Known or suspected neuromyelitis optica spectrum disorder with severe, recurrent, or bilateral optic neuritis (25)
• Suspected retinoblastoma (26,27)
• For approved indications as noted above and being performed in a child under 8 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial pathology (28)

INDICATIONS FOR FACE/SINUS MRI
Face/Sinus MRI

• Rhinosinusitis (29)
  • Clinical suspicion of fungal infection (30)
  • Clinical suspicion of orbital or intracranial complications,(16,17) such as;
    • Preseptal, orbital, or central nervous system infection
    • Osteomyelitis
    • Cavernous sinus thrombosis
• Sinonasal obstruction, suspected mass, based on exam, nasal endoscopy, or prior imaging (29,31)
• Anosmia or Dysosmia that is persistent and of unknown origin after a thorough history and nasal and neurological examination (32,33)
• Suspected infection
  • Osteomyelitis (after x-rays) (34)
  • Abscess based on clinical signs and symptoms of infection
• Face mass (29,35,36)
  • Present on physical exam and remains non-diagnostic after x-ray or ultrasound is completed
  • Known or highly suspected head and neck cancer on examination
  • Failed 2 weeks of treatment for suspected infectious adenopathy (37)
• Facial trauma (38)
  • Concern for soft tissue injury to further evaluate for treatment or surgical planning (39)
• Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease (30)
• Trigeminal neuralgia/neuropathy (for evaluation of the extracranial nerve course)
  • If atypical features (e.g., bilateral, hearing loss, dizziness/vertigo, visual changes, sensory loss, numbness, pain > 2 min, pain outside trigeminal nerve distribution, progression) (32,40)

NOTE: ADDITIONAL ONCOLOGIC FACE/SINUS MRI INDICATIONS

Indications for Combination Studies
Face/Sinus and Brain MRI Combination Studies

• Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease (41)
• Trigeminal neuralgia that meets the above criteria (32,40)
• For approved indications as noted above and being performed in a child under 8 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial pathology (28)

INDICATIONS FOR NECK MRI
Suspected tumor or cancer (42)

• Suspicious lesions in mouth or throat (36)
• Suspicious mass/tumor found on another imaging study and needing clarification
• Neck mass or lymphadenopathy (non-parotid or non-thyroid)
  • Present on physical exam and remains non-diagnostic after ultrasound is completed
  • Mass or abnormality found on other imaging study and needing further evaluation
  • Increased risk for malignancy with one or more of the following findings:(43)
    • Fixation to adjacent tissues
    • Firm consistency
    • Size >1.5 cm
    • Ulceration of overlying skin
    • Mass present ≥ two weeks (or uncertain duration) without significant fluctuation and not considered of infectious cause
    • History of cancer
  • Failed 2 weeks of treatment for suspected infectious adenopathy (37)
  • Pediatric (≤18 years old) considerations (44)
    • Ultrasound should be inconclusive or suspicious unless there is a history of malignancy(23)

Note: For discrete cystic lesions of the neck, an ultrasound should be performed as initial imaging unless there is a high suspicion of malignancy

• Neck Mass (parotid) (42)
  • Parotid mass found on other imaging study and needing further evaluation (US is the initial imaging study of a parotid region mass)
• Neck Mass (thyroid) (45)
  • Staging and monitoring for recurrence of known thyroid cancer
  • To assess extent of thyroid tissue when other imaging suggests extension through the thoracic inlet into the mediastinum or concern for airway compression (46,47)

Note: US is the initial imaging study of a thyroid region mass. Biopsy is usually the next step. In the evaluation of known thyroid malignancy, CT is preferred over MRI since there is less respiratory motion artifact. Chest CT may be included for preoperative assessment in some cases.

Other indications for a Neck MRI

• Known or suspected deep space infections or abscesses of the pharynx or neck with signs or symptoms of infection (48)
• MR Sialography to evaluate salivary ducts (49,50)
• Vocal cord lesions or vocal cord paralysis (51)
• Unexplained ear pain when ordered by a specialist with all of the following (52)
  • Otoscopic exam, nasolaryngoscopy, lab evaluation (ESR, CBC) AND
  • Risk factor for malignancy i.e., tobacco use, alcohol use, dysphagia, weight loss OR age older than 50 years
• Diagnosed primary hyperparathyroidism when surgery is planned
  • Previous nondiagnostic ultrasound or nuclear medicine scan (53,54)
• Hereditary Paraganglioma-Pheochromocytoma (PGL/PCC) Syndrome (SDHx mutations) every 2 years when whole body MRI (CPT 76498) is not available
• Bell’s palsy/hemifacial spasm (for evaluation of the extracranial nerve course)
  • If atypical signs, slow resolution beyond three weeks, no improvement at four months, or facial twitching/spasms prior to onset (55)
• Objective cranial nerve palsy (CN IX-XII) (for evaluation of the extracranial nerve course) (32,56)
• Brachial plexopathy (57)
  • Traumatic Brachial Plexopathy: If mechanism of injury is highly suspicious for brachial plexopathy (such as mid-clavicular fracture, shoulder dislocation, contact injury to the neck (burner or stinger syndrome) or penetrating injury)
  • Non-traumatic Brachial Plexopathy when Electromyography/Nerve Conduction Velocity (EMG/NCV) studies are suggestive of brachial plexopathy

NOTE: Either Neck MRI, Shoulder MRI or Chest MRI may be appropriate depending on the location of the injury/plexopathy. Only one of these three studies is indicated.

NOTE: ADDITIONAL ONCOLOGIC NECK MRI INDICATIONS

Indications for Combination Studies
Neck and Brain MRI Combination Studies

• Objective cranial nerve palsy (CN IX-XII) (for evaluation of the extracranial nerve course) (32,56)
• Bell’s Palsy/hemifacial spasm that meets the above criteria (55)
• For approved indications as noted above and being performed in a child under 8 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial pathology (28)

Chest CT and Neck /Abdomen MRI

• PGL/PCC (Hereditary Paraganglioma/Pheochromocytoma syndromes or SDHx mutations): every 2 years IF whole body MRI (unlisted MRI CPT 76498) not available(58) (see Unlisted Studies Evolent_CG_063) (59)

Neck/Face CT or MRI and PET

• Neck/Face CT or MRI is indicated in addition to PET for Head and Neck Cancer
  • For surgical or radiation planning
  • 3-4 months after end of treatment in patients with locoregionally advanced disease or with altered anatomy

INDICATIONS FOR INTERNAL AUDITORY CANAL (IAC) MRI
Not Including Brain

• Unilateral non-pulsatile tinnitus
• Pulsatile tinnitus
• Suspected acoustic neuroma (Schwannoma) or cerebellar pontine angle tumor with any of the following signs and symptoms: unilateral hearing loss by audiometry, headache, disturbed balance or gait, unilateral tinnitus, facial weakness, or altered sense of taste
• Suspected cholesteatoma
• Suspected glomus tumor
• Asymmetric sensorineural hearing loss on audiogram
• Congenital/childhood sensorineural hearing loss suspected to be due to a structural abnormality (60,61,62) (CNVIII, the brain parenchyma, or the membranous labyrinth). CT 
• is the preferred imaging modality for the osseous anatomy and malformations of the inner ear.
• CSF otorrhea (MRI/Nuclear Cisternography for intermittent leaks, CT for active leaks); there should be a high suspicion or confirmatory CSF fluid laboratory testing (Beta-2 transferrin assay)
• Bell’s Palsy for evaluation of the extracranial nerve course -if atypical signs, slow resolution beyond three weeks, no improvement at four months, or facial twitching/spasms prior to onset (55)

ADDITIONAL ONCOLOGIC INDICATIONS 
Abdomen/Neck/Pelvis MRI and Chest CT

• PGL/PCC (Hereditary Paraganglioma/Pheochromocytoma syndromes or SDHx mutations): every 2 years IF whole body MRI (unlisted MRI CPT 76498) NOT available (58) (see Unlisted Studies Evolent_CG_063) (59)

Neck/Face CT or MRI and PET

• Neck/Face CT or MRI is indicated in addition to PET for Head and Neck Cancer
  • For surgical or radiation planning
  • 3-4 months after end of treatment in patients with locoregionally advanced disease or with altered anatomy

Orbit/Face/Sinus/Neck MRI
Follow-up of known Tumor or Cancer (63)

• For initial staging, restaging, and suspected recurrence of head and neck cancer 
• Head and Neck cancer annually when specified that the area of original disease is difficult to follow on direct visualization (surveillance is typically with exam/scope rather than imaging)

Combination Studies for Malignancy for Initial Staging or Restaging
Unless otherwise specified in this guideline, indication for combination studies for malignancy for initial staging or restaging:

• Concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Abdomen, Brain, Chest, Neck, Pelvis, Cervical Spine, Thoracic Spine or Lumbar Spine.

PRE-OPERATIVE/PROCEDURAL EVALUATION

• Pre-operative evaluation for a planned surgery or procedure

POST-OPERATIVE/PROCEDURAL EVALUATION

• When imaging, physical, or laboratory findings indicate surgical or procedural complications

FURTHER EVALUATION OF INDETERMINATE FINDINGS ON PRIOR IMAGING
Unless follow-up is otherwise specified within the guideline:

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification (35)
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam)

GENETICS AND RARE DISEASES

• PGL/PCC (Hereditary Paraganglioma/Pheochromocytoma syndromes or SDHx mutations): every 2 years IF whole body MRI (unlisted MRI CPT 76498) NOT available (58) (see Unlisted Studies Evolent_CG_063) (59)
• For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance

LEGISLATIVE REQUIREMENTS
State of Washington (64)
Washington State Health Care Authority Technology Assessment: Health Technology Clinical Committee

Number and Coverage Topic:
Imaging for Rhinosinusitis

HTTC Coverage Determination:
Imaging for Rhinosinusitis is a covered benefit with conditions consistent with the criteria identified in the reimbursement determination.

HTCC Reimbursement Determination:
Limitations of Coverage
Imaging with Sinus Computed Tomography (CT) is covered in the context of rhinosinusitis for the following:

• Red Flags* OR
• Persistent Symptoms** > 12 weeks AND failure of medical therapy; OR
• Surgical planning
• Repeat scanning is not covered except for Red Flags or Surgical Planning

Magnetic Resonance Imaging (MRI) of the sinus is covered in the context of rhinosinusitis for the following:

• As above for sinus CT AND < 18 years of age OR pregnant

*Red Flags in the setting of Rhinosinusitis: (From American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS))

• Swelling of orbit
• Altered mental status
• Neurological findings
• Signs of meningeal irritation
• Severe headache
• Signs of intracranial complication, including, but not limited to:
  • Meningitis,
  • Intracerebral abscess
  • Cavernous sinus thrombosis
• Involvement of nearby structures, including, but not limited to:
  • Periorbital cellulitis

**Persistent Symptoms defined as ≥ two of the following: (From AAO-HNS)

• Facial pain-pressure-fullness
• Mucopurulent drainage
• Nasal obstruction (congestion)
• Decreased sense of smell

Non-Covered Indicators

• Imaging of the sinus for rhinosinusitis using X-ray OR Ultrasound is not covered.

Rationale

Sinus
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.

Anosmia
Nonstructural causes of anosmia include post viral symptoms, medications (Amitriptyline, Enalapril, Nifedipine, Propranolol, Penicillamine, Sumatriptan, Cisplatin, Trifluoperazine, Propylthiouracil). These should be considered prior to advanced imaging to look for a structural cause. Anosmia and dysgeusia have been reported as common early symptoms in patients with COVID-19, occurring in greater than 80 percent of patients. For isolated anosmia, imaging is typically not needed once the diagnosis of COVID has been made given the high association. As such, COVID testing should be done prior to imaging (65,66,67) MRI Orbits, Face, and Neck MRI rather than MRI Brain is the mainstay for directly imaging the olfactory apparatus and sinonasal or anterior cranial fossa tumors that may impair or directly involve the olfactory apparatus. (68)

CSF (Cerebrospinal Fluid) Leaks
For CSF rhinorrhea, Sinus CT is indicated when looking to characterize a bony defect. For CSF otorrhea, Temporal Bone CT is indicated. For intermittent leaks and complex cases, consider CT/MRI/Nuclear Cisternography. There should be a high suspicion or confirmatory CSF fluid laboratory testing (Beta-2 transferrin assay). (69,70)

Trigeminal Neuralgia
According to the International Headache Society, Trigeminal Neuralgia (TN) is defined as a disorder characterized by recurrent unilateral brief electric shock-like pain, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve and triggered by innocuous stimuli. (71)

Contraindication 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

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Coding Section 

Code	Number	Description
CPT	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
	0698T	Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic mri examination of the same anatomy (eg, organ, gland, tissue, target structure); multiple organs (list separately in addition to code for primary procedure)

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.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward     

11/11/2024	Annual review, oliccy updated for clarity and consistency, contraindications/preferred study section added, expanded combination section, clarified traumatic vs non traumatic brachial plexopathy, added hereditary paraganglioma-pheochromocytoma, added follow up known cancer section. Also updating rationale and references.
01/01/2024	New Policy