mp-177 - Medical Policies - Alabama
Magnetic Resonance Neurography
Policy Number: MP-177
Latest Review Date: November 2019
Policy Grade: C
Magnetic resonance neurography is considered not medically necessary for coverage and is considered investigational.
DESCRIPTION OF PROCEDURE OR SERVICE:
Magnetic resonance neurography (MRN) is a novel imaging technique recently developed for direct imaging of spinal and peripheral nerves. Modifications are made to standard MRI technology using special software and hardware upgrades that enable direct high-resolution longitudinal and cross-sectional images of peripheral nerves such that the morphology of the nerve can be visualized. MRN has been studied to supplement diagnostic evaluations by electromyography (EMG) and nerve conduction studies (NCS) in patients with suspected peripheral nerve tumors, traumatic injury, post-irradiation neuritis, chronic compression, and pain syndromes where an anatomic lesion is suspected.
The most recent literature review was performed through November 20, 2019.
Summary of Evidence
Although current evidence supports MRN as a promising technique, the outcome data which would determine the efficacy of this technology is limited to studies involving a small number of patients, making it premature to offer conclusions regarding its effectiveness for the general population. Additionally, large-scale, well-conducted, controlled studies with this approach are warranted to determine its efficacy in imaging neurofibromas and distinguishing benign from malignant lesions.
Currently, the sensitivity, specificity, as well as positive predictive value (PPV) and negative predictive value (NPV) of MRN in the diagnosis and management of patients with peripheral nerve disorders remain unclear. Thus, the accuracy and clinical value of Magnetic resonance neurography has yet to be established.
Magnetic resonance neurography, MRN, Magnetic resonance neurogram, MR Neurography, MR Imaging of Peripheral Nerves, PNI
APPROVED BY GOVERNING BODIES:
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply.
FEP: Special benefit consideration may apply. Refer to member’s benefit plan. FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.
There are no specific codes for magnetic resonance neurography.
Unlisted magnetic resonance procedure (e.g., diagnostic, interventional)
Unlisted Procedure, Nervous System
Bendszus M, Stoll G. Technology insight: visualizing peripheral nerve injury using MRI. Nat Clin Pract Neurol. 2005 Nov; 1(1):45-53. Review.
Du R, Auguste KI, Chin CT, Engstrom JW, Weinstein PR. Magnetic resonance neurography for the evaluation of peripheral nerve, brachial plexus, and nerve root disorders. J Neurosurg. 2010 Feb; 112(2):362-71.
Filler AG, Haynes J, Jordan SE, Prager J, Villablanca JP, Farahani K, et al. Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J Neurosurg Spine. 2005 Feb; 2(2):99-115.
Filler AG, Kliot M, Howe FA, Hayes CE, Saunders DE, Goodkin R, et al. Application of magnetic resonance neurography in the evaluation of patients with peripheral nerve pathology. J Neurosurg. 1996 Aug; 85(2):299-309.
Filler AG, Maravilla KR, Tsuruda JS. MR neurography and muscle MR imaging for image diagnosis of disorders affecting the peripheral nerves and musculature. Neurol Clin. 2004 Aug; 22(3):643-82, vi-vii.
Grant GA, Goodkin R, Maravilla KR, Kliot M. MR neurography: diagnostic utility in the surgical treatment of peripheral nerve disorders. Neuroimaging Clin N Am. 2004 Feb; 14(1):115-33.
Hilgenfeld T, Jende J, Schwarz D, et al. Somatotopic fascicular lesions of the brachial plexus demonstrated by high-resolution magnetic resonance neurography. Invest Radiol. 2017; 52(12):741-746.
Kronlage M, Schwehr V, Schwarz D, et al. Magnetic resonance neurography: Normal values and demographic determinants of nerve caliber and T2 relaxometry in 60 healthy individuals. Clin Neuroradiol. 2017 Oct 13
Zhang Z, Song L, Meng Q, et al. Morphological analysis in patients with sciatica: A magnetic resonance imaging study using three-dimensional high-resolution diffusion-weighted magnetic resonance neurography techniques. Spine. 2009; 34(7):E245-E250.
Medical Policy Group, June, 2011 (1): Policy created
Medical Policy Administration Committee, July, 2011
Available for comment July 6 through August 22, 2011
Medical Policy Group, July 2015 (3): Policy reviewed by consensus with radiology CMO at CCN; no new literature to add; service remains investigational; no change in policy statement
Medical Policy Group, September 2018 (3) Updates to Key Points and References. No changes to policy statement or intent.
Medical Policy Group, November 2019 (3): 2019 Updates to Key Points and Key Words: added: MR Neurography, MR Imaging of Peripheral Nerves, PNI. No changes to policy statement or intent.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.