ORBIT, FACE, NECK, SINUS MRI - CAM 738

Description
Magnetic resonance imaging (MRI) is used in the evaluation of face and neck region masses, trauma, and infection. The soft-tissue contrast between normal and abnormal tissues provided by MRI is sensitive for differentiating between inflammatory disease and malignant tumors and permits the precise delineation of tumor margins. MRI is used for therapy planning and follow-up of face and neck neoplasms. It is also used for the evaluation of neck lymphadenopathy and vocal cord lesions.

CT scanning remains the study of choice for the imaging evaluation of acute and chronic inflammatory diseases of the sinonasal cavities. MRI is not considered the first-line study for routine sinus imaging because of limitations in the definition of the bony anatomy and length of imaging time. MRI for confirmation of diagnosis of sinusitis is discouraged because of hypersensitivity (overdiagnosis) in comparison to CT without contrast. MRI, however, is superior to CT in differentiating inflammatory conditions from neoplastic processes. MRI may better depict intraorbital and intracranial complications in cases of aggressive sinus infection, as well as differentiating soft-tissue masses from inflammatory mucosal disease. MRI may also identify fungal invasive sinusitis or encephaloceles.

Anosmia - Nonstructural causes of anosmia include post viral symptoms, medications (Amitiptyline, Enalapril, Nifedipine, Propranolol, Penicillamine, Sumatriptan, Cisplatin, Triflouperazine, Propylthiouracil). These should be considered prior to advanced imaging to look for a structural cause. 

Policy 
ORBIT MRI is considered MEDICALLY NECESSARY for the following indications: 

INDICATIONS FOR ORBIT MRI:
MRI is superior for the evaluation of the visual pathways, globe and soft tissues, CT is preferred for visualizing bony detail and calcifications (Hande, 2012; Kennedy, 2018)   

  • Abnormal external or direct eye exam
    • Exophthalmos (proptosis) or enophthalmos
    • Ophthalmoplegia with concern for orbital pathology
    • Unilateral optic disk swelling (Hata, 2017; Margolin, 2019; Passi, 2013)
    • Documented visual field defect (Fadzil, 2013; Kedar, 2011; Prasad, 2012; Sadun, 2011)
      • Unilateral or with abnormal optic disc(s) (e.g., optic disc blurring, edema, or pallor); AND
      • Not explained by underlying diagnosis, glaucoma, or macular degeneration
  • Optic neuritis (CMSC, 2018; Gala, 2015; Srikajon, 2018; Voss, 2011)
    • If atypical presentation, severe visual impairment, or poor recovery following initial onset or treatment onset OR
    • If needed to confirm optic neuritis and rule out compressive lesions
  • Orbital trauma (Lin, 2012; Sung, 2014)
    • Physical findings of direct eye injury
    • Suspected orbital trauma with indeterminate x-ray or ultrasound
  • Orbital or ocular mass/tumor, suspected or known (Hande, 2012; Kedar, 2011)
  • Clinical suspicion of orbital infection (Hande, 2012; Kennedy, 2018)
  • Clinical suspicion of osteomyelitis (Arunkumar, 2011; Lee, 2016)
    • Direct visualization of bony deformity OR
    • Abnormal x-rays
  • Clinical suspicion of Orbital Inflammatory Disease (e.g., eye pain and restricted eye movement with suspected orbital pseudotumor) (Pakdaman, 2014)
  • Congenital orbital anomalies
  • Complex strabismus to aid in diagnosis, treatment and/or surgical planning (Demer, 2002; Kadom, 2008)

INDICATIONS FOR ORBIT AND BRAIN MRI COMBINATION STUDIES:

  • Optic neuropathy or unilateral optic disk swelling of unclear etiology to distinguish between a compressive lesion of the optic nerve, optic neuritis, ischemic optic neuropathy (arteritic or non-arteritic), central retinal vein occlusion or optic nerve infiltrative disorders (Behbehani, 2007)
  • Bilateral optic disk swelling (papilledema) with vision loss (Margolin, 2019) • Optic neuritis if atypical presentation, severe visual impairment, or poor recovery following initial onset or treatment onset (CMSC, 2018)
  • Known or suspected neuromyelitis optica spectrum disorder with severe, recurrent, or bilateral optic neuritis (Wingerchuk, 2015)
  • For approved indications as noted above and being performed in a child under 8 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial pathology (Lawson, 2000)

INDICATIONS FOR FACE/SINUS MRI:

  • Rhinosinusitis (Kirsch, 2017)
    • Clinical suspicion of fungal infection (Gavito-Higuera, 2016)
    • Clinical suspicion of orbital or intracranial complications (Arunkumar, 2011; Lee, 2016), such as
      • Preseptal, orbital, or central nervous system infection
      • Osteomyelitis
      • Cavernous sinus thrombosis
  • Sinonasal obstruction, suspected mass, based on exam, nasal endoscopy, or prior imaging (Kirsch, 2017; Rosenfeld, 2015)
  • Suspected infection
    • Osteomyelitis (after x-rays) (Pincus, 2009)
    • Abscess
  • Anosmia or Dysosmia based on objective testing that is persistent and of unknown origin (Policeni, 2017; Rouby, 2011; Zaghouani, 2013)
  • Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease (Pakalniskis, 2015)
  • Face mass (Kirsch, 2017; Koeller, 2016; Kuno, 2014):
    • Present on physical exam and remains non-diagnostic after x-ray or ultrasound is completed
    • Known or highly suspected head and neck cancer on examination (Kirsch, 2017)
    • Failed 2 weeks of treatment for suspected infectious adenopathy (Haynes, 2015)
  • Facial trauma (Echo, 2010; Lin, 2012; Raju, 2017; Sung, 2014)
    • Physical findings of direct facial bone injury.
    • For further evaluation of a known fracture for treatment or surgical planning

Note: CSF (cerebrospinal fluid) rhinorrhea - Sinus CT is indicated when looking to characterize a bony defect. CSF otorrhea - Temporal Bone CT is indicated. For intermittent leaks and complex cases, consider CT/MRI/Nuclear Cisternography). CSF fluid should always be confirmed with laboratory testing (Beta-2 transferrin assay)

  • Trigeminal neuralgia/neuropathy (for evaluation of the extracranial nerve course)
    • If atypical features (e.g., bilateral, hearing loss, dizziness/vertigo, visual changes, sensory loss, numbness, pain > 2min, pain outside trigeminal nerve distribution, progression) (ACR, 2017; Hughes, 2016; Policeni, 2017)

INDICATIONS FOR FACE/SINUS AND BRAIN MRI COMBINATION STUDIES:

  • Anosmia or dysosmia on objective testing that is persistent and of unknown origin (ACR, 2017; Decker, 2013; Policeni, 2017; Zaghouani, 2013)
  • Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease (Pakalniskis, 2015)
  • Trigeminal neuralgia that meets the above criteria (Hughes 2016; Policeni, 2017)
  • For approved indications as noted above and being performed in a child under 8 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial pathology (Lawson, 2000).

INDICATIONS FOR NECK MRI:

Suspected tumor or cancer: (ACR, 2018a)

  • Suspicious lesions in mouth or throat (Kuno, 2014).
  • Suspicious mass/tumor found on another imaging study and needing clarification
  • Neck mass or lymphadenopathy (non-parotid or thyroid)
  • Present on physical exam and remains non-diagnostic after ultrasound is completed (Kuno, 2014)

Note: For discrete cystic lesions of the neck, an ultrasound should be performed as initial imaging unless there is a high suspicion of malignancy

    • Increased risk for malignancy with one or more of the following findings (Pynnonen, 2017):
      • Fixation to adjacent tissues
      • Firm consistency
      • Size >1.5 cm
      • Ulceration of overlying skin
      • Mass present ≥ two weeks (or uncertain duration) without significant fluctuation and not considered of infectious cause
      • History of cancer
    • Failed 2 weeks of treatment for suspected infectious adenopathy (Haynes, 2015).
  • Neck Mass (parotid) (ACR, 2018a)
    • Parotid mass found on other imaging study and needing further evaluation (US is the initial imaging study of a parotid region mass)
  • Neck Mass (thyroid) (ACR, 2018b)
    • Staging and monitoring for recurrence of known thyroid cancer (ACR, 2018b).
    • To assess extent of thyroid tissue when other imaging suggests extension through the thoracic inlet into the mediastinum or concern for airway compression (Gharib 2016; Lin, 2016)

Suspected tumor or cancer: (ACR, 2018a)

  • Suspicious lesions in mouth or throat (Kuno, 2014).
  • Suspicious mass/tumor found on another imaging study and needing clarification
  • Neck mass or lymphadenopathy (non-parotid or thyroid)
  • Present on physical exam and remains non-diagnostic after ultrasound is completed (Kuno, 2014) 

Note: For discrete cystic lesions of the neck, an ultrasound should be performed as initial imaging unless there is a high suspicion of malignancy 

    • Increased risk for malignancy with one or more of the following findings (Pynnonen, 2017):
      • Fixation to adjacent tissues
      • Firm consistency
      • Size >1.5 cm
      • Ulceration of overlying skin
      • Mass present ≥ two weeks (or uncertain duration) without significant fluctuation and not considered of infectious cause
      • History of cancer
    • Failed 2 weeks of treatment for suspected infectious adenopathy (Haynes, 2015).
  • Neck Mass (parotid) (ACR, 2018a)
    • Parotid mass found on other imaging study and needing further evaluation (US is the initial imaging study of a parotid region mass)
  • Neck Mass (thyroid) (ACR, 2018b)
    • Staging and monitoring for recurrence of known thyroid cancer (ACR, 2018b).
    • To assess extent of thyroid tissue when other imaging suggests extension through the thoracic inlet into the mediastinum or concern for airway compression (Gharib 2016; Lin, 2016)

Note: US is the initial imaging study of a thyroid region mass. CT is preferred over MRI in the evaluation of thyroid masses since there is less respiratory motion artifact. Chest CT may be included for preoperative assessment in some cases

US is the initial imaging study of a thyroid region mass. CT is preferred over MRI in the evaluation of thyroid masses since there is less respiratory motion artifact. Chest CT may be included for preoperative assessment in some cases

Pediatric patients (≤ 18 years old): (Wai, 2020)

  • Neck masses if ultrasound is inconclusive or suspicious (Brown, 2016)
  • History of malignancy

Known or suspected deep space infections or abscesses of the pharynx or neck (Meyer, 2009)

Other indications for a Neck MRI:

  • MR Sialography to evaluate salivary ducts (Burke, 2011; Ren, 2015)
  • Vocal cord lesions or vocal cord paralysis (Dankbaar, 2014).
  • Unexplained ear pain when ordered by a specialist with all of the following (Earwood, 2018)
    • Otoscopic exam, nasolaryngoscopy, lab evaluation (ESR, CBC) AND
    • Risk factor for malignancy i.e., tobacco use, alcohol use, dysphagia, weight loss OR age older than 50 years
  • Diagnosed primary hyperparathyroidism when surgery is planned
    • Previous nondiagnostic ultrasound or nuclear medicine scan (Khan, 2014; Piciucchi, 2012).
  • Bell’s palsy/hemifacial spasm (for evaluation of the extracranial nerve course)
    • If atypical signs, slow resolution beyond three weeks, no improvement at four months, or facial twitching/spasms prior to onset (Quesnel, 2010)
  • Objective cranial nerve palsy (CN IX-XII) (for evaluation of the extracranial nerve course) (ACR, 2017; Mumtaz, 2014; Policeni, 2017)
  • Brachial plexopathy if mechanism of injury or EMG/NCV studies are suggestive (Vijayasarathi, 2016)

Note: Chest MRI is preferred study, but neck and/or shoulder (upper extremity) MRI can be ordered depending on the suspected location of injury

INDICATIONS FOR NECK AND BRAIN MRI COMBINATION STUDIES:

  • Objective cranial nerve palsy (CN IX-XII) (for evaluation of the extracranial nerve course) (ACR, 2017; Mumtaz, 2014; Policeni, 2017)
  • For approved indications as noted above and being performed in a child under 8 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial pathology (Lawson, 2000).

OTHER INDICATIONS FOR ORBIT/FACE/SINUS/NECK MRI

Known tumor or cancer of skull base, orbits, sinuses, face, tongue, larynx, nasopharynx, pharynx, or salivary glands

  • Initial staging (Kuno, 2014)
  • Restaging during treatment
  • Suspected recurrence or new metastases based on symptoms or examination findings
    • New mass
    • Change in lymph nodes (Hoang, 2013)
  • Surveillance appropriate for tumor type and stage

Indication for combination studies for the initial pre-therapy staging of cancer, OR active monitoring for recurrence as clinically indicated OR evaluation of suspected metastases

  • < 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine or Lumbar Spine

Pre-operative/procedural evaluation

  • Pre-operative evaluation for a planned surgery or procedure

Post- operative/procedural evaluation

  • When imaging, physical, or laboratory findings indicate surgical or procedural complications

 All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY. 

 References 

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Coding Section 

Code Number Description
CPT 70540 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)
  70542 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)
  70543 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2019 Forward     

11/01/2021 

Annual review, adding criteria related to complex strabismus, temporal bone fracture, optic neuritis, compressive lesions. Clarifying language regarding visual defect, osteomyelitis, optic neuropathy, csf otorrhea. No other changes. 

11/01/2020 

Annual review, updating policy for clarifications and facial trauma and metastases. Also updating references and background. 

11/25/2019

New Policy

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