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Medical Policy: 06.01.08
Original Effective Date: January 2003
Reviewed: October 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Magnetic Resonance Spectroscopy (MRS) is a non-invasive technique that can detect and measure concentrations of low molecular weight chemicals within living body tissues. MRS is similar to magnetic resonance imaging (MRI) and can be performed with modified MRI equipment. The primary difference between MRI and MRS is that MRS detects the chemical composition of the tissue, while MRI provides an image of the anatomy. MRS has been investigated as an analytical tool to study metabolic changes in brain tumors, stroke, Alzheimer's disease, and epilepsy.
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Prior Approval:
Not applicable
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Policy:
Magnetic resonance spectroscopy is considered investigational for all conditions.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 76390 magnetic resonance spectroscopy.
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Selected References:
- Burtscher LM, Holtas S. Proton magnetic resonance spectroscopy in brain tumors: clinical applications. Neuroradiology 2001;43:345-352.
- Moller-Hartmann W, Herninghaus S, Krings T, Marquardt G, Lanfermann H, Pilatus U, Zanella FE. Clinical application of proton magnetic resonance spectroscopy in the diagnosis of intracranial mass lesions. Neuroradiology 2002;44:371-381.
- Norfray JF, Tomita T, Byrd SE, Ross BD, Berger PA, Miller RS. Clinical impact of MR Spectroscopy when MR imaging is indeterminate for pediatric brain tumors. American Journal of Radiology 1999 July;173: 119-125.
- Shukala-Dave A, Gupta RK, Roy R et al. Prospective evaluation of in vivo proton MR spectroscopy in differentiation of similar appearing intracranial cystic lesions. Magn Reson Imaging 2001; 19(1):103-10.
- Soares DP, Law M. Magnetic resonance spectroscopy of the brain: review of metabolites and clinical applications. Clin Radiol. 2009 Jan;64(1):12-21.
- Tran T, Ross B, Lin A. Magnetic resonance spectroscopy in neurological diagnosis. Neurol Clin. 2009 Feb;27(1):21-60.
- ECRI Institute. Magnetic Resonance Spectroscopy for Screening, Diagnosis, and Staging of Prostate Cancer. Plymouth Meeting (PA): ECRI Institute; 2009 March 6. 10 p. [ECRI hotline response]. Also available: http://www.ecri.org
- Kauppinen RA, Peet AC. Using magnetic resonance imaging and spectroscopy in cancer diagnostics and monitoring: Preclinical and clinical approaches. Cancer Biol Ther. 2011 Oct 15;12(8):665-79.
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Policy History:
Date Reason Action
August 2010 Annual review Policy renewed
October 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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