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Medical Policy: 06.01.27
Original Effective Date: October 2008
Reviewed: September 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:
Determining the cause of back pain is a complex task. In some patients, extensive evaluation with various imaging modalities does not lead to a definitive diagnosis. Some recent studies have suggested that imaging the body in various positions with “loading” of the spine may lead to more accurate diagnosis. This loading can be accomplished by having the patient stand or sit. Also, imaging can be completed with the patient in the position that cases the symptoms(s). This is being evaluated in suspected nerve root compression and in some cases of spondylolisthesis.
A new open magnetic resonance imaging (MRI) system has been developed that allows imaging of the patient in various positions. The imaging can be conducted with partial or full weight bearing. Dynamic-kinetic imaging (images obtained during movement) can also be obtained with this system. Conventional MR imaging is completed with the patient in a recumbent position. Of note, weight-bearing images of the spine can be simulated by imaging in the supine position in combination with a special axial loading device.
FONAR Corporation has 510(k) marketing clearance from the U.S. Food and Drug Administration (FDA) for a MRI system that performs positional MRI scans (i.e., FONAR’s Upright® MRI).
In evaluating this approach to imaging, it is important to first determine if positional MRI results in additional findings. However, it is also important to determine if treatment of these additional findings results in improved outcomes. A number of studies have reported that positional MRI can identify abnormalities in patients where conventional MRI did not identify significant abnormal findings. Yet, no studies have described clinical outcomes of patients whose treatments were selected on the new findings of positional MRI. Additionally, the incremental benefit of this imaging in clinical practice is not yet known.
While this imaging approach is interesting, published results are in an early phase. Additional study is needed to first determine the characteristics of patients who might benefit from positional MRI studies. In addition, the clinical benefit of basing treatment decisions, including surgery, on these additional findings need to be established. Another concern that needs further study is that positional scans, which use lower strength magnets, may be of lesser quality than those from traditional supine MRI. Studies are also needed to determine if this technique might replace current diagnostic tests, such as myelography.
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Prior Approval:
Not applicable
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Policy:
Positional (non-recumbent) magnetic resonance imaging (MRI) is considered investigational, including its use in the evaluation of patients with cervical, thoracic, or lumbosacral pain.
No studies have been found that described clinical outcomes of patients whose treatments were selected on the new findings of positional MRI, and the incremental benefit of this imaging in clinical practice is not yet known. The clinical benefit of basing treatment decisions, including surgery, on these additional findings needs to be established. Another concern that needs further study is that positional scans, which use lower strength magnets, may be of lesser quality than those from traditional supine MRI. Further comparison with axial-loaded supine MRI is needed. The scientific evidence at th is time does not permit conclusions concerning the effect of this technology on health outcomes.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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76498 Unlisted magnetic resonance procedure (eg, diagnostic, interventional)
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Selected References:
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Jarvik JJ, Hollingworth W, Heagerty P et al. The longitudinal assessment of imaging and disability of the back (LAIDBack) study: baseline data. Spine 2001; 26(10):1158-66.
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Jinkins JR, Dworkin JS, Damadian RV. Upright, weight-bearing, dynamic-kinetic MRI of the spine: initial results. Eur Radiol 2005; 15(9):1815-25.
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Madsen R, Jensen TS, Pope M et al. The effect of body position and axial load on spinal canal morphology: an MRI study of central spinal stenosis. Spine 2008; 33(1):61-7.
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Vitaz TW, Shields CB, Raque GH et al. Dynamic weight-bearing cervical magnetic resonance imaging: technical review and preliminary results. South Med J 2004; 97(5):456-61.
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Weishaupt D, Schmid MR, Zanetti M et al. Positional MR imaging of the lumbar spine: does it demonstrate nerve root compromise not visible at conventional MR imaging? Radiology 2000; 215(1):247-53.
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Kanno H, Endo T, Ozawa H et al. Axial loading during magnetic resonance imaging in patients with lumbar spinal cabal stenosis: does it reproduce the positional change of the dural sac detected by upright myelography? Spine (Phila Pa 1076) 2011 Jan 20 [Epub ahead of print].
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Policy History:
Date Reason Action
September 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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