2021 Magellan Advanced Imaging Guidelines - RADMD

1 Copyright 2019-2020 National Imaging Associates, Inc., All Rights Reserved National Imaging Associates, Inc.* 2021 Magellan Clinical Guidelines For Medical Necessity Review Advanced Imaging Guidelines Effective January 1, 2021 December 31, 2021 *National Imaging Associates, Inc. (NIA) is a subsidiary of Magellan Healthcare, Inc. 2021 Magellan Clinical Guidelines - Advanced Imaging 2 Guidelines for Clinical Review Determination Preamble Magellan is committed to the philosophy of supporting safe and effective treatment for patients. The medical necessity criteria that follow are Guidelines for the provision of diagnostic Imaging . These criteria are designed to guide both providers and reviewers to the most appropriate diagnostic tests based on a patient s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice will be used when applying the Guidelines .

2 Determinations are made based on both the guideline and clinical information provided at the time of the request. It is expected that medical necessity decisions may change as new evidence-based information is provided or based on unique aspects of the patient s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient. 2021 Magellan Clinical Guidelines - Advanced Imaging 3 Guideline Development Process These medical necessity criteria were developed by Magellan Healthcare for the purpose of making clinical review determinations for requests for therapies and diagnostic procedures. The developers of the criteria sets included representatives from the disciplines of radiology, internal medicine, nursing, cardiology, and other specialty groups. Magellan s Guidelines are reviewed yearly and modified when necessary following a literature search of pertinent and established clinical Guidelines and accepted diagnostic Imaging practices.

3 All inquiries should be directed to: Magellan Healthcare PO Box 67390 Phoenix, AZ 85082-7390 Attn: Magellan Healthcare Chief Medical Officer 2021 Magellan Clinical Guidelines - Advanced Imaging 4 Table of contents Advanced Imaging Guidelines 70336 MRI Temporomandibular Joint .. 6 70450 CT Head/Brain .. 10 70480 CT TEMPORAL BONE, MASTOID, ORBITS .. 35 70486 CT Maxillofacial/Sinus .. 44 70490 CT Soft Tissue Neck .. 52 70496 CT Angiography, Head .. 59 70498 CT Angiography, Neck .. 70 70540 MRI Orbit, Face, and/or Neck .. 77 70544 MR Angiography Head/Brain .. 90 70547 MR Angiography Neck .. 103 70551 MRI Brain (includes Internal Auditory Canal) .. 110 70554 Functional MRI Brain .. 148 71250 CT Chest (Thorax) .. 152 71275 CT Angiography, Chest (non coronary) .. 165 71550 MRI Chest (Thorax) .. 173 71555 MR Angiography Chest .. 180 72125 CT Cervical Spine.

4 187 72128 CT Thoracic Spine .. 198 72131 CT Lumbar Spine .. 209 72141 MRI Cervical Spine .. 221 72146 MRI Thoracic Spine .. 234 72148 MRI Lumbar Spine .. 246 72159 MR Angiography Spinal Canal .. 258 72191 CT Angiography, Pelvis .. 261 72192 CT Pelvis .. 268 72196 MRI Pelvis .. 278 72198 MR Angiography, Pelvis .. 291 73200 CT Upper Extremity .. 298 73206 CT Angiography, Upper Extremity .. 314 73220 MRI Upper Extremity .. 319 73225 MR Angiography Upper Extremity .. 332 73700 CT Lower Extremity (Ankle, Foot, Hip or Knee) .. 337 73706 CT Angiography, Lower Extremity .. 351 73720 MRI Lower Extremity .. 357 73725 MR Angiography, Lower Extremity .. 374 74150 CT Abdomen .. 379 74174 CT Angiography, Abdomen and Pelvis .. 395 2021 Magellan Clinical Guidelines - Advanced Imaging 5 74175 CT Angiography, Abdomen .. 403 74176 CT Abdomen and Pelvis Combination.

5 410 74181 MRI MRCP Abdomen .. 428 74185 MR Angiography, Abdomen .. 447 74261 CT Colonoscopy Diagnostic (Virtual) .. 455 74263 CT Colonoscopy Screening (Virtual) .. 458 74712 Fetal MRI .. 462 75557 MRI Heart .. 465 75571 Electron Beam Tomography (EBCT) .. 481 75572 CT Heart .. 486 75573 CT Heart Congenital Studies .. 486 75574 CTA Coronary Arteries (CCTA) .. 495 75635 CT Angiography, Abdominal Arteries .. 508 76376 3D Rendering (CT Multiplanar Reconstruction) .. 512 76380 Follow-Up, Limited or Localized CT .. 513 76390 MR Spectroscopy .. 514 76497 Unlisted CT Procedure .. 518 76498 Unlisted MRI Procedure .. 518 77012 CT Needle Guidance .. 519 77021 MRI Needle Guidance .. 519 77046 MRI Breast .. 520 77078 CT Bone Density Study .. 534 77084 MRI Bone Marrow .. 539 78429 HEART PET with CT for Attenuation .. 543 78451 Myocardial Perfusion Imaging .. 557 78459 PET Scan, Heart (Cardiac).

6 571 78472 MUGA Scan .. 584 78608 PET Scan, Brain .. 588 78803 Radiopharmaceutical Tumor Localization (SPECT), Single Area .. 593 78813 PET Scans .. 619 78813 PET Scans with CT Attenuation .. 619 0042T Cerebral Prefusion CT .. 640 G0219 PET Imaging whole body, melanoma - noncovered .. 645 G0235 PET Imaging , any site, not otherwise specified .. 647 G0252 PET Imaging , initial diagnosis of breast cancer .. 648 G0297 Low Dose CT for Lung Cancer Screening .. 649 S8042 Low Field MRI .. 654 2021 Magellan Clinical Guidelines - Advanced Imaging 6 70336 MRI Temporomandibular Joint CPT Code: 70336 INDICATIONS FOR TEMPOROMANDIBULAR JOINT (TMJ) MRI: For evaluation of temporomandibular joint dysfunction (TMD) with suspected internal joint derangement with ALL of the following (Bag, 2014; Gauer, 2015.)

7 Petscavage, 2014): Persistent symptoms of facial or jaw pain, restricted range of motion, pain and/or noise with TMJ function ( , chewing) (Bag, 2014) Conservative therapy with a trial of anti-inflammatory AND behavioral modification has been unsuccessful for at least four (4) weeks Initial X-rays have been performed For evaluation of Juvenile idiopathic arthritis (JIA) (Granquist, 2018, Petscavage-Thomas, 2014) Abnormal initial x-ray or ultrasound needing additional Imaging (Bag, 2014) Pre-operative evaluation in candidates for orthognathic surgery Post-Operative Evaluation (Hoffman, 2015) A follow-up study may be needed to help evaluate a patient s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional Imaging is needed for the type and area(s) requested. BACKGROUND: Temporomandibular joint (TMJ) dysfunction causes pain and dysfunction in the jaw joint and muscles controlling jaw movement.

8 Symptoms may include: jaw pain, masticator muscle stiffness, limited movement or locking of the jaw, clicking or popping in jaw joint when opening or closing the mouth, and a change in how the upper and lower teeth fit together. The cause of the condition is not always clear but may include acute or chronic trauma to the jaw or temporomandibular joint, , grinding of teeth, clenching of jaw, or impact in an accident. Osteoarthritis or rheumatoid arthritis may also contribute to the condition. Etiologies of TMJ dysfunction include intra-articular (intracapsular) and extra-articular (extracapsular pathology). Intra-articular (intracapsular pathology) ie disc displacement and coexisting osteoarthritis or degenerative joint disease is considered the most common cause of serious TMJ pain and dysfunction and the most likely to be treated surgically. Extra-articular (extracapsular pathology) includes: musculoskeletal (bone, masticatory muscles and tendons) and central nervous system/peripheral nervous system (ASTMJS, 2001).

9 TABLE OF CONTENTS 2021 Magellan Clinical Guidelines - Advanced Imaging 7 Imaging can assist in the diagnosis of TMD when history and physical examination findings are equivocal. The initial study should be plain radiography (transcranial and transmaxillary views) or panoramic radiography (Gauer, 2015). Ultrasound is an inexpensive and easily performed Imaging modality that can also be used to evaluate the TMJ (Tu, 2018). CT is useful to evaluate the bony structures of the TMJ when there is suspicion of bony involvement ( , fractures, erosions, infection, invasion by tumor, as well as congenital anomalies) (Bag, 2014). Magnetic resonance Imaging (MRI) has the highest sensitivity, specificity, and accuracy in the evaluation of temporomandibular joint dysfunction and provides tissue contrast for visualizing the soft tissue and periarticular structures of the TMJ. Conservative care for TMD includes patient education, self-care, behavioral modification, cognitive behavioral therapy/biofeedback, medication, physical therapy and occlusive devices, Medications include NSAIDS and muscle relaxants and in chronic cases, benzodiazepines or antidepressants.

10 There is lack of high-quality evidence and uncertainty about the effectiveness of manual therapy and therapeutic physical therapy in treating TMJ dysfunction. (Armijo-Olivo, 2016). The use of occlusive splints is thought to alleviate some of the degenerative forces on the TMJ which may be helpful in patients with bruxism or nocturnal teeth clenching. The preferred devices are unclear from the literature and dental consultation is required (Gauer, 2015). In systematic reviews, there has been short term benefit observed from splinting but no clear role in the overall long-term treatment of TMD patients (Ebrahim, 2012; Pficer, 2017). POLICY HISTORY: Review Date: May 2019 Review Summary: Updated background information and references Review Date: May 2020 Review Summary: Added: For evaluation of temporomandibular joint dysfunction (TMD) with suspected internal joint derangement with ALL of the following o Persistent symptoms of facial or jaw pain, restricted range of motion, pain and/or noise with TMJ function ( , chewing) o Conservative therapy with a trial of anti-inflammatory AND behavioral modification has been unsuccessful for at least four (4) weeks o Initial X-rays have been performed For evaluation of Juvenile idiopathic arthritis (JIA) Abnormal initial x-ray or ultrasound needing additional Imaging Deleted.