Response to Comments: MRI and CT Scans of Head and Neck

There is no general rule that requires other diagnostic tests to be tried before CT scanning is used. However, in individual cases it may be determined that use of a CT scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the patient’s symptoms or complaints as stated on the claim.

Agree, and sometimes other earlier tests or data may indicate the need for a CT scan, such as evidence of a metastatic lesion known to spread to the brain.

CT imaging has not been useful in general for the evaluation of headache or dizziness and should be reserved for the patient whose presentation indicates a focal problem or who has experienced a significant change in symptomatology.

Agree

A CT scan for the diagnosis of headache (ICD-10 code G44.1) can be allowed for the following:

1. After a head injury to rule out intracranial bleeding
2. Headache unusual in duration (greater than two weeks) not responding to medical therapy, to rule out the possibility of a tumor
3. A headache characterized by sudden onset and severity to rule out the possibility of an aneurysm, bleeding and/or arteriovenous malformation

Usually there is some sign or symptom, and it would depend on the injury, but we agree these may be indications, depending on the severity and other factors, particularly when a MRI is not immediately available.

A CT Scan may be ordered without contrast, with contrast, or without contrast followed by contrast. Contrast administration is not without risk to the patient, and for some conditions, adds little or no benefit to the patient. The general indications for use of contrast CT scanning (as opposed to non-contrast scanning) are to:

1. Assess perfusion (e.g. CVA)
2. Characterize a specific lesion
3. Detect defects in blood/brain barrier (e.g. infarct, tumor, infection, vasculitis)
4. Detect neovascularity (tumor), and
5. For staging of known lung cancer, breast cancer, and lymphomas likely to metastasize early to the brain

Agree

Intravenous contrast generally adds no information to CT scans done secondary to head trauma. Additional symptoms suggesting a possible intracranial bleed may justify the use of contrast. These symptoms should be documented in the medical record, and if appropriate, included in the diagnostic codes listed on the claim.

Agree

More than one contrast CT scan per episode of illness adds no information with the following exceptions.

More than 1 CT is appropriate when there are sudden changes in condition of symptoms. There is considerable radiation exposure in CT and avoidance of unnecessary radiation is a goal. The exceptions below should be documented.

1. CVA
2. Non-traumatic hemorrhage
3. TIA
4. Post-operative scan for residual tumor
5. Known brain tumor/metastases with a change in mental status or other evidence of CNS change..

Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic scanning technique that employs a powerful and highly uniform static magnetic field, rather than ionizing radiation, to produce images. Fluctuations in the strength of the magnetic field alter the motion and relaxation times of hydrogen molecules, which are related to the density of molecules and reflect the physicochemical properties of the tissues. Reconstructed images can be displayed in multiple planes to facilitate analysis. See national non-coverage in CMS section above.

Coverage is limited to those CT and MRI machines that have received pre-market approval by the FDA. Such units must be operated within the parameters specified by the approval. Inconclusive findings on a CT scan may warrant a MRI study and, conversely, findings of a MRI study may be further clarified (under certain circumstances) with a subsequent CT scan. The information provided by the two modalities may be complementary.

Agree.

Cancer Staging. Clinicians commonly use CT and MRI of the brain when metastatic involvement is suspected.

Non-covered indications: esophagus, oropharynx, and prostate, and non- melanoma skin cancer in the absence of symptoms of brain involvement. “Certain tumors almost never metastasize to the brain parenchyma. These include carcinomas of the esophagus, oropharynx, and prostate, and non- melanoma skin cancers.” (DeVita, Chapter 52.1) Accordingly, the related diagnoses found in the following diagnosis code list do not justify brain scans for “staging” purposes unless a patient has signs or symptoms suggesting brain involvement. Covered: In contrast, for those malignancies that commonly metastasize to the brain, staging in the absence of neurological findings may be appropriate.

Agree. It is noted that more recent references were suggested, but none provided.

Payment will be allowed for reasonable and necessary scans of different areas of the body that are performed on the same day and are not subject to this policy.

No response needed.

We suggest that "thunderclap Headaches" be accepted as a diagnosis that would allow Head CT (or MRI) imaging

Agree, use G44.53 as a covered diagnosis for Primary thunderclap headache.

We suggest that fractures be accepted as a diagnosis that would allow Head CT,

Agree and S02.40AA-S02.40FS will be added as these are the only fracture codes of the head not in the draft LCD.

We suggest that "More than one contrast CT per episode of illness" be allowed for mass effect, hydrocephalus. and CNS infections such as brain abscess.

Agree, G91.0-G92, A39.89, A81.89, A81.9, A9231 along with other multiple head and neck infections are listed in the ICD-10 Codes that Support Medical Necessity section of the LCD. If there are problems, individual appeal is always available.

We agree with the statement that CT and MRI  may be complimentary imaging modalities which should be similarly stated in other CT and MRI LCD policies, such as the MRI Lumbar LCD Policy.

This policy is separate from MRI or CT in other areas.

We suggest that malignancies that may metastasize to the bone such as skull be allowed for MRI or CT of the Head and Neck when indicated with appropriate symptoms and signs.

We agree. As an example, prostate cancer metastasized to the skull or spine causing mass effect on the brain or spinal canal would be logically coded and accepted C97.51 with C61.

We agree with the statement "that a radiologist may not be able to document the medical necessity of a procedure." Again when compared with the Lumbar MRI draft LCD, we question whether a radiologist is capable of adequately documenting in the written report the medical necessity and treatment conditions, which would be only found in the referring MD records. We prefer the MRI and CT Scans of the Head and Neck wording and recommend change/modification of the Lumbar MRI LCD draft policy to that of the MRI and CT Scans of the Head and Neck LCD Draft Policy. 

The wording in the Lumbar MRI has been clarified.

The LCD notes the following ICD-10-CM codes do not denote medical necessity for early MRI. We would suggest that they be included as indications for acute MRI. In this list, “#” indicates all applicable subheadings within a given family of codes. We would encourage Noridian to make the following changes, and to review the remainder of the codes for accuracy:

M80.08# Age-related osteoporosis with current pathological fracture, vertebra(e)

M84.35# Stress fracture, pelvis

M84.454# Pathological fracture, pelvis

S22.0# Fracture of thoracic vertebra

S23.0# Traumatic rupture of thoracic intervertebral disc

S23.1# Subluxation and dislocation of thoracic vertebra

S24.# Injury of nerves and spinal cord at thoracic level

S32.0# Fracture of lumbar vertebra

S32.1# Fracture of sacrum

S32.31# Fracture of ilium

S32.81# Fractures of pelvis with disruption of pelvic ring

S32.82# Fractures of pelvis without disruption of pelvic ring

S32.89# Fracture of other parts of pelvis

S33.0XX# Traumatic disruption of lumbar intervertebral disc

S33.1# Subluxation and dislocation of lumbar vertebra

S34.# Injury of lumbar and sacral spinal cord and nerves

S34.3# Injury of the cauda equina (it is very disconcerting that injury to the cauda equina, S34.3XXA, an indication for emergent surgery, is not an indication for emergent MRI examination. This will force mis-coding on the part of physicians to obtain clinically appropriate studies.)

T85.618# Breakdown (mechanical) of other specified internal prosthetic devices, implants and grafts

T85.620# Displacement of cranial or spinal infusion catheter

T85.625# Displacement of other nervous system device, implant or graft

T85.890# Other specified complication of nervous system prosthetic devices

This policy is only related to CT/MRI of head and neck. T85.620 and T85.890 are listed as payable diagnoses in the policy as they could relate to the head and neck.

It was recommended that MRI might be useful for staging or localizing areas of epilepsy (possibly prior to surgical or other treatment) or transverse myelitis. 

Agree, all appropriate diagnosis codes are listed as payable in the policy.

A significant number of comments were sent regarding thoracolumbar MRI studies and wanted additional ICD-10 codes added.

Thoracolumbar MRI studies are not related to this particular policy. The ICD-10 codes requested were of areas other than the head and neck, and dealt with other conditions (use of anticoagulants, general falls, etc.) that would be covered with additional documentation or would be very rare and covered as individual exception if appealed.