Clinical UM Guideline

Subject:CT/MRI Brain and Head
Guideline #:  CG-RAD-11Current Effective Date:  04/21/2010
Status:RevisedLast Review Date:  02/25/2010
Description

This document addresses the use of both computed tomography (CT) and magnetic resonance imaging (MRI) in the outpatient setting for the diagnosis, evaluation and management of brain and head-related conditions. There are many overlapping indications for MRI and CT scan. Imaging modality may depend on availability or specific individual circumstances (see Discussion section below).

Note: Please see the following related documents for additional information:

Clinical Indications

Computed Tomography 

Medically Necessary
CT of the head or brain is considered medically necessary for any of the following: 

A. Recent History of Head Trauma (followed by one or more of the following symptoms)

B. Cerebrovascular Accident (CVA), Stroke or Transient Ischemic Attack (TIA)

 C. Infection or Inflammatory Conditions (known or suspected)

D. Headache
CT of the head or brain in an adult is considered medically necessary for the evaluation of headache for any of the following:

CT of the head or brain in children is considered medically necessary for the evaluation of headache when any of the above criteria have been met, or any of the following additional criteria have been met:

E. Malignant (primary or metastatic) and Benign Lesions (known or suspected)

F. Demyelinating and Dysmyelinating Disease (e.g., multiple sclerosis, acute disseminated acute encephalomyelitis, leukodystrophies, central pontine myelinolysis and progressive multifocal leukoencephalopathy) for any of the following when MRI is not tolerated or contraindicated:

G. Congenital Anomalies:

H. Vascular Abnormalities

I. Hemorrhage or Hematoma

 J. Central Nervous System (CNS) Signs or Symptoms, evaluation of new onset or worsening of any of the following:

K. Other CNS Conditions

L. Related to Neurosurgical Procedures

M. Other

Not Medically Necessary
CT of the head or brain is considered not medically necessary for any of the following:

Repeat imaging of the same body part by the same or similar imaging technology, when there is no change in clinical status (e.g., deterioration), persistent diagnostic problem, or medical intervention which warrants interval re-assessment is considered not medically necessary for CT head or brain except where specified above as medically necessary. 

Magnetic Resonance Imaging 

Medically Necessary
MRI head or brain is considered medically necessary for any of the following:

A. Recent History of Head Trauma (followed by one or more of the following symptoms)

B. Cerebrovascular Accident (CVA), Stroke or Transient Ischemic Attack (TIA)

 C. Infection or Inflammatory Conditions (known or suspected)

D. Headache
MRI of the head or brain in an adult is considered medically necessary for the evaluation of headache for any of the following:

MRI of the head or brain in children is considered medically necessary for the evaluation of headache when any of the above criteria have been met, or any of the following additional criteria have been met:

E. Malignant (primary or metastatic) and Benign Lesions (known or suspected)

F. Demyelinating and Dysmyelinating Disease (e.g., multiple sclerosis, acute disseminated acute encephalomyelitis, leukodystrophies, central pontine myelinolysis and progressive multifocal leukoencephalopathy) for any of the following:

G. Congenital Anomalies

H. Vascular abnormalities

I. Hemorrhage or Hematoma

J. Central Nervous System (CNS) Signs or Symptoms, evaluation of new onset or worsening of any of the following:

K. Other CNS Conditions

L. Related to Neurosurgical Procedures:

M. Other

Not Medically Necessary
MRI of the head or brain is considered not medically necessary for any of the following:

Repeat imaging of the same body part by the same or similar imaging technology, when there is no change in clinical status (e.g., deterioration), persistent diagnostic problem, or medical intervention which warrants interval re-assessment is considered not medically necessary for MRI head or brain except where specified above as medically necessary.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
 CT
70450Computed tomography, head or brain; without contrast material
70460Computed tomography, head or brain; with contrast material(s)
70470Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections
76380Computed tomography, limited or localized follow-up study
  
 MRI
70551Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material
70552Magnetic resonance (e.g., proton) imaging, brain (including brain stem); with contrast material(s)
70553Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences
  
 CPT/HCPCS code modifiers:
-26Professional component
-TCTechnical component
  
ICD-9 Diagnosis 
 All diagnoses
  
Discussion/General Information

Computed tomography (CT) is a diagnostic tool that uses special x-ray equipment to obtain image data from different angles around the body, then uses computer processing of the information to show a cross-section of body tissues and organs. The CT requires less time than MRI and can be performed in acute settings where advanced monitoring and life support is needed for an unstable individual.

Magnetic resonance imaging (MRI) is a diagnostic technique that uses a cylindrical magnet and radio waves to produce high quality multiplanar images of organs and structures within the body without x-rays or radiation. The body's hydrogen atoms react to the magnetic field and pulses of radio waves. This reaction is changed to an image by a computer.

The ability of either CT or MRI to image structures in the brain and head in the indications listed above summarize the most signs, symptoms and conditions. As noted in the Clinical Indications, there are many overlapping indications for CT and MRI. Imaging modality will depend on the specific indication and individual circumstances. The following situations describe indications where there is a relative preference of one imaging technique over another.

Imaging Preference Based on Indication

General

Head Trauma or Hemorrhage

Tumors

Cerebrovascular Accident (CVA), Stroke or Transient Ischemic Attack (TIA)

Infection or Inflammatory Conditions

Imaging Preferences Based on Individual Circumstances
The following are examples of specific individual characteristics that may dictate the preference of one imaging modality over another.

References

Peer Reviewed Publications:

  1. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007; 357(22):2277-2284.
  2. Connor SE, Jarosz JM. Magnetic resonance imaging of cerebral venous sinus thrombosis. Clin Radiol. 2002; 57(6):449-461.
  3. Hoggard N, Wilkinson ID, Paley MN, Griffiths PD. Imaging of hemorrhagic stroke. Clin Radiol. 2002; 57(11):957-968.
  4. Kidwell CS, Saver JL, Villablanca JP et al. Magnetic resonance imaging detection of microbleeds before thrombolysis: an emerging application. Stroke. 2002; 33(1):95-98.
  5. Levin HS, Hanten G, Roberson G, et al. Prediction of cognitive sequelae based on abnormal computed tomography findings in children following mild traumatic brain injury. J Neurosurg Pediatrics. 2008; 1(6):461-470.
  6. Poser CM, Brinar VV. Diagnostic criteria for multiple sclerosis. Clin Neurol Neurosurg. 2001; 103(1):1-11.
  7. Rother J. CT and MRI in the diagnosis of acute stroke and their role in thrombolysis. Thromb Res. 2001; 103(Suppl 1):S125-133.
  8. Rubin A, Zafar, S. The assessment and management of the dizzy patient. Otolaryngol Clin North Am. 2002; 35(2):255-273.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American Academy of Neurology; Practice Committee of the Child Neurology Society. Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2004; 62(6):851-863.
  2. American Academy of Neurology; Practice Committee of the Child Neurology Society. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002; 59(4):490-498.
  3. American Academy of Neurology; Practice Committee of the Child Neurology Society. Practice parameter: evaluation of the child with global developmental delay: report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society. Neurology. 2003; 60(3):367-380.
  4. American Academy of Pediatrics. Practice Guideline: The management of minor closed head injury in children. 2007. Available at http://www.aafp.org/online/en/home/clinical/clinicalrecs/headinjurychild.html. Accessed on January 4, 2010.
  5. American College of Radiology. ACR Appropriateness Criteria®: Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx. Accessed on January 13, 2010.
    • Ataxia. (2009)
    • Cerebrovascular Disease. (2006)
    • Dementia and Movement Disorders. (2007)
    • Epilepsy. (2006)
    • Focal Neurologic Deficit. (2008)
    • Head trauma. (2008)
    • Headache. (2009)
    • Orbits, Vision and Visual Loss. (2009)
    • Primary Bone Tumors. (2009)
    • Soft Tissue Masses. (2009)
    • Vertigo and hearing loss. (2006)
  6. American College of Radiology. Practice guideline: Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx. Accessed on January 13, 2010.
    • Performance of computed tomography (CT) of the brain. (2006)
    • Performance of computed tomography (CT) of the extracranial head and neck in adults and children. (2006)
    • Performance and interpretation of magnetic resonance imaging (MRI) of the brain. (2008)
  7. Centers for Medicare and Medicaid Services. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on January 13, 2010.
    • National Coverage Determination: Computerized Tomography. NCD# 220.1. Effective March 12, 2008.
    • National Coverage Determination: Magnetic Resonance Imaging (MRI). NCD #220.2. Effective September 28, 2009.
  8. Frohman E, Goodin D, Calabresi P, et al. The utility of MRI in suspected MS: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2003; 61(5):602–611.
  9. Harden CL, Huff JS, Schwartz TH, et al. Reassessment: Neuroimaging in the emergency patient presenting with seizure (an evidence-based review) Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007; 69(18):1772-1780.
  10. Knopman D, DeKosky S, Cummings J, et al. Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001; 56(9):1143-1153.
  11. Krumholz A, Wiebe S, Gronseth G, et al. Practice Parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review) Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2007; 69(21):1996-2007. 
  12. Lewis DW. Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002; 59(4):490-498.
  13. Riviello JJ, Ashwal S, Hirtz D, et al. Practice Parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review) Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society Neurology. 2006; 67(9):1542-1550.
  14. Shevell M. Evaluation of the child with global developmental delay: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2003; 60(3):367-380.
  15. Silberstein S. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55(6):754-762.  
Index

Arteriovenous Malformations
Brain
Central Nervous System
Cerebrovascular Accident (CVA)
Chiari I & II Malformations
Computed Tomography (CT)
Dementia
Head
Head Trauma
Headache
Hydrocephalus
Magnetic Resonance Imaging (MRI)
Papilledema
Pituitary Lesion
Seizure
Syncope
Vertigo

History

Status

Date

Action

Revised02/25/2010Medical Policy & Technology Assessment Committee (MPTAC) review. Addition of "when MRI is not tolerated" to CT criteria for demyelinating disease. Deletion of "craniosynostosis" from MRI criteria. Added Not Medically Necessary statements: "Repeat imaging of the same body part by the same or similar imaging technology, when there is no change in clinical status (e.g., deterioration), persistent diagnostic problem, or medical intervention which warrants interval re-assessment is considered not medically necessary for CT head or brain except where specified above as medically necessary" and "Repeat imaging of the same body part by the same or similar imaging technology, when there is no change in clinical status (e.g., deterioration), persistent diagnostic problem, or medical intervention which warrants interval re-assessment is considered not medically necessary for MRI head or brain except where specified above as medically necessary." Updated Coding, References and Websites.
Revised11/19/2009MPTAC review. Addition of "confusion or disorientation" to headache portion of CT and MRI head criteria, addition of "Vertigo or Dizziness" to CT and MRI head criteria, addition of "increased" to intracranial pressure or herniation for CT head criteria, addition of "or increasing frequency or severity of established seizure disorder" to CT and MRI head criteria, addition of "Abnormalities detected on other imaging studies which require additional clarification to direct treatment" to CT and MRI head criteria, addition of "Ventricular shunt assessment" to CT and MRI head criteria. Updated references and websites.
 06/15/2009Medically necessary statements re-formatted.
Revised02/26/2009MPTAC review. Separated indications into categories for CT and MRI. Additions and deletions to medically necessary and not medically necessary statements. Updated references, websites, description section and discussion/general information section. Removed Place of Service section.
Revised02/21/2008MPTAC review. Added note regarding radiation exposure. Added pituitary adenomas to medically necessary statement for evaluation of malignant and benign lesions of the brain and head. Added clarifying information to the medically necessary statement regarding endocrine abnormalities that suggest the presence of a pituitary lesion (under section IX. Other CNS indications). Updated Coding and Reference sections.
Reviewed03/08/2007MPTAC review. No change to position statement; updated coding.
Revised03/23/2006MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem Virginia

07/20/2005

 CT/MRI Brain and Head
WellPoint Health Networks, Inc.

07/14/2005

Clinical GuidelineCT/MRI Brain and Head