Medical Policy: 06.01.08
Original Effective Date: January 2003
Reviewed: June 2015
Revised: June 2015
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.
Magnetic Resonance Spectroscopy (MRS), also known as nuclear magnetic resonance (NMR) spectroscopy, is a non-invasive technique that can detect and measure different chemical components within tissues (i.e. amino acids, lipid, lactate, alanine, n-acetyl aspartate, choline, creatinine, myoinositol). MRS has been used to study metabolic changes in brain tumors, strokes, seizure disorders, Alzheimer’s disease, depression and other diseases affecting the brain. It has also been used to study the metabolism of other organs. Peripheral applications of MRS include the study of myocardial ischemia, peripheral vascular disease, and skeletal muscle.
MRS is similar to magnetic resonance imaging (MRI) and can be performed with modified MRI equipment. The primary difference between MRI and MRS is the MRI provides an image of the anatomy and the MRS creates a graph or spectrum arraying the types and quantity of chemicals in the brain or other organs.
The role of MRS in diagnosis and therapeutic planning has not be established by adequate clinical studies. Specifically, there have been no clinical trials demonstrating improved outcomes in patients evaluated with MRS compared to patients evaluated with conventional modalities. Further clinical trials are needed to determine the usefulness of this procedure. In addition, the techniques of acquiring the MRS spectra and interpreting the results are not well standardized.
Magnetic resonance spectroscopy is considered investigational for all indications including, but not limited to:
- Psychiatric disorders
- ADHD (attention deficit/hyperactivity disorder)
- Bipolar disorder
- Obsessive-compulsive disorder
- Dementia (e.g. Alzheimer's disease, demential with Lewy bodies, frontotemporal dementia, vascular dementia)
- Hepatic encephalopathy
- Movement disorders (e.g. Huntington disease, Parkinson/Parkinsonian syndromes)
- Multiple Sclerosis
- Cerebrovascular injury
- Seizure disorders
- Liver disease
- Myocardial disease/ischemia
- Peripheral vascular disease
- Brain Tumors
- Prostate cancer
- Brease cancer
The role of MRS in diagnosis and therapeutic planning has not been established by adequate clinical studies. Specifically, there has been no clinical trials demonstrating improved outcomes in patients evaluated with MRS compared to patients evaluatd with conventional modalities and studies do not clearly delineate how MRS information would be used to guide patient management. In addition, the techniques of acquiring the MRS spectra and interpreting the results are not well standardized. The scientific evidence at this time does not permit conclusions concerning the net effect of this technology on health outcomes and further clinical trials are needed to determine the usefulness of this procedure. Therefore, the use of MRS is considered investigational.
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.
- 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].
- 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.
- Klijn S, DeVisschere PJ, De Meerleer GO, Villeirs GM. Comparison of qualitative and quantitative approach to prostate MR spectroscopy in peripheral zone cancer detection. Eur J Radiol. 2012 Mar;81(3):411-6.
- Pinto F, Totaro A, Palermo G, et al. Imaging in prostate cancer staging: present role and future perspectives. Urol Into. 2012;88(2):125-36.
- ECRI Institute. Magnetic Resonance Spectroscopy for Screening and Managing Prostate Cancer. Plymouth Meeting (PA): ECRI Health Technology Assessment Information Service. April 2012. [Hotline Response].
- Liu ZL, Zhou Q, Zeng QS, et al. Noninvasive evaluation of cerebral glioma grade by using diffusion-weighted imaging-guided single-voxel proton magnetic resonance spectroscopy. J Int Med Res. 2012;40(1):76-84.
- Centers for Medicare and Medicaid Services, National Coverage Determination (NCD) for Magnetic Resonance Spectroscopy (220.2.1). Also available at www.cms.gov/medicare-coverage-database
- National Guideline Clearinghouse. ACR Appropriateness Criteria Dementia and Movement Disorders, 2014. Also available at www.guideline.gov
- National Comprehensive Cancer Network (NCCN) Central Nervous System Cancers Version 1.2015. Also available at www.nccn.org
- National Comprehensive Cancer Network (NCCN) Prostate Cancer Version 1.2015. Also available at www.nccn.org
- National Comprehensive Cancer Network (NCCN) Invasive Breast Cancer Version 2.2015. Also available at www.nccn.org
- National Institute for Health and Care Excellence (NICE), Do Not Do Recommendation for Men with Prostate Cancer. Also available at www.nice.org
- National Insitute for Health and Care Excellence (NICE) Parkinson’s Disease: Diagnosis and Management in Primary and Secondary Setting. Also available at www.nice.org
- Hudsmith Lucy E, MA, MRCP, Stefan Neubauer, M.D., FRCP. Magnetic Resonance Spectroscopy in Myocardial Disease. JACC: Cardiovascular Imaging, Vol. 2. No. 1, 2009
- Befroy Douglas E., Shulman Gerald I. Magnetic Resonance Spectroscopy Studies of Human Metabolism, Diabetes, Col. 60, May 2011
- UpToDate. Hepatic Encephalopathy in Adults: Clinical Manifestations and Diagnosis, Peter Ferenci, M.D., Topic last updated May 5, 2015. Also available at www.uptodate.com
- UpToDate. Epidemiology, Clinical Features, and Diagnosis of Nonalcoholic Fatty Liver Disease in Adults, Sunil G Sheth,M.D., Sunjiv Chopra, M.D., MACP, Topic last updated December 10, 2014. Also available at www.uptodate.com
- UpToDate. Neuroimaging Studies in the Evaluation of Dementia, Normal Relkin, M.D., PhD. Topic last updated October 21, 2014. Also available at www.uptodate.com
- UpToDate. Clinical Presentation and Diagnosis of Brain Tumors, Eric T Wong, M.D., Julian K. Wu, M.D., Topic last updated September 26, 2014. Also available at www.uptodate.com
- UpToDate. MRI of the Breast and Emerging Technologies, Priscilla J. Slanetz, M.D., MPH, FACR, Topic last updated July 2, 2014. Also available at www.uptodate.com
Date Reason Action
August 2010 Annual review Policy renewed
October 2011 Annual review Policy renewed
October 2012 Annual review Policy renewed
September 2013 Annual review Policy renewed
July 2014 Annual review Policy revised
June 2015 Annual review Policy revised
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 © 2012 American Medical Association. All Rights Reserved.