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 (Amitriptyline, Enalapril, Nifedipine, Propranolol, Penicillamine, Sumatriptan, Cisplatin, Trifluoperazine, Propylthiouracil). These should be considered prior to advanced imaging to look for a structural cause. Anosmia and dysgeusia have been reported as common early symptoms in patients with COVID-19, occurring in greater than 80 percent of patients. For isolated anosmia, imaging is typically not needed once the diagnosis of COVID has been made given the high association. As such, COVID testing should be done prior to imaging.^66,67,68

MRI orbits, face, and neck MRI rather than MRI brain is the mainstay for directly imaging the olfactory apparatus and sinonasal or anterior cranial fossa tumors that may impair or directly involve the olfactory apparatus.³³

CSF (cerebrospinal fluid) leaks — For CSF rhinorrhea, Sinus CT is indicated when looking to characterize a bony defect. For CSF otorrhea, temporal bone CT is indicated. For intermittent leaks and complex cases, consider CT/MRI/nuclear cisternography. There should be a high suspicion or confirmatory CSF fluid laboratory testing (Beta-2 transferrin assay).^69,70

Trigeminal Neuralgia — According to the International Headache Society, TN is defined as “a disorder characterized by recurrent unilateral brief electric shock-like pain, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve and triggered by innocuous stimuli.”⁷¹

General Information

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

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

INDICATIONS FOR ORBIT MRI:
If there is a combination request* for an overlapping body part, either requested at the same time or sequentially (within the past 3 months) the results of the prior study should be:

• Inconclusive or show a need for additional or follow up imaging evaluation OR
• The office notes should clearly document an indication why overlapping imaging is needed and how it will change management for the patient.

(*Unless approvable in the combination section as noted in the guidelines)
MRI is superior for the evaluation of the visual pathways, globe and soft tissues; CT is preferred for visualizing bony detail and calcifications^1,2

• Abnormal external or direct eye exam
  • Exophthalmos (proptosis) or enophthalmos
  • Ophthalmoplegia with concern for orbital pathology
  • Unilateral optic disk swelling^3,4,5
  • Documented visual field defect^6,7,8,9
  • 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^{10,11,12,13,14}
  • If atypical presentation (bilateral, absence of pain, optic nerve hemorrhages, severe visual impairment, lack of response to steroids, poor recovery or recurrence)^15,16
  • If needed to confirm optic neuritis and rule out compressive lesions
• Orbital trauma^17,18
  • Physical findings of direct eye injury
  • Suspected orbital trauma with indeterminate X-ray or ultrasound
• Orbital or ocular mass/tumor, suspected or known^1,7
• Clinical suspicion of orbital infection^1,2
• Clinical suspicion of osteomyelitis^19,20
  • 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)²¹
• Congenital orbital anomalies
• Complex strabismus syndromes (with ophthalmoplegia or ophthalmoparesis) to aid in diagnosis, treatment and/or surgical planning^22,23,24

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 disorders²⁵
• Bilateral optic disk swelling (papilledema) with vision loss3
• Optic neuritis
  • If atypical presentation (bilateral, absence of pain, optic nerve hemorrhages, severe visual impairment, lack of response to steroids, poor recovery or recurrence)^{11,12,13,14,15,16}
  • If needed to confirm optic neuritis and rule out compressive lesions
• Known or suspected neuromyelitis optica spectrum disorder with severe, recurrent, or bilateral optic neuritis26
• Suspected retinoblastoma^27,28
• 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 pathology²⁹

INDICATIONS FOR FACE/SINUS MRI:

• Rhinosinusitis³⁰
  • Clinical suspicion of fungal infection31
  • Clinical suspicion of orbital or intracranial complications,^{19, 20} 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^30,32
• Anosmia or dysosmia based on objective testing that is persistent and of unknown origin^33,34,35
• Suspected infection
  • Osteomyelitis (after X-rays)³⁶
  • Abscess based on clinical signs and symptoms of infection
• Face mass^30,37,38
  • Present on physical exam and remains non-diagnostic after X-ray or ultrasound is completed
  • Known or highly suspected head and neck cancer on examination³⁰
  • Failed 2 weeks of treatment for suspected infectious adenopathy³⁹
• Facial trauma^17,18,40,41
  • Concern for soft tissue injury to further evaluate for treatment or surgical planning⁴²
• Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease³¹
• 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 > 2 min, pain outside trigeminal nerve distribution, progression)^33,43

 
INDICATIONS FOR FACE/SINUS AND BRAIN MRI COMBINATION STUDIES:

• Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease⁴⁴
• Trigeminal neuralgia that meets the above criteria^33,43
• 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 pathology²⁹

INDICATIONS FOR NECK MRI:
Suspected tumor or cancer:⁴⁵

• Suspicious lesions in mouth or throat³⁸
• Suspicious mass/tumor found on another imaging study and needing clarification
• Neck mass or lymphadenopathy (non-parotid or non-thyroid)
  • Present on physical exam and remains non-diagnostic after ultrasound is completed³⁸
  • Mass or abnormality found on other imaging study and needing further evaluation
  • Increased risk for malignancy with one or more of the following findings:⁴⁶
    • 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 adenopathy³⁹
  • Pediatric (≤ 18 years old) considerations¹⁰
    • Ultrasound should be inconclusive or suspicious unless there is a history of malignancy¹¹

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

• Neck Mass (parotid)⁴⁵
  • 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)⁴⁷
  • Staging and monitoring for recurrence of known thyroid cancer⁴⁷
    • To assess extent of thyroid tissue when other imaging suggests extension through the thoracic inlet into the mediastinum or concern for airway compression^48,49

Note: US is the initial imaging study of a thyroid region mass. Biopsy is usually the next step. In the evaluation of known thyroid malignancy, CT is preferred over MRI since there is less respiratory motion artifact. Chest CT may be included for preoperative assessment in some cases

Known or suspected deep space infections or abscesses of the pharynx or neck with signs or symptoms of infection⁵⁰

Other indications for a Neck MRI:

• MR Sialography to evaluate salivary ducts^51,52
• Vocal cord lesions or vocal cord paralysis⁵³
• Unexplained ear pain when ordered by a specialist with all of the following⁵⁴
  • 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^55,56
• 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 onset⁵⁷
• Objective cranial nerve palsy (CN IX-XII) (for evaluation of the extracranial nerve course)^33,58
• Brachial plexopathy if mechanism of injury or EMG/NCV studies are suggestive^59,60

Note: Chest MRI is preferred study, but neck and/or shoulder (upper extremity) MRI can be approved 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)^33,58
• Bell’s Palsy/hemifacial spasm that meets the above criteria⁵⁷
• 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 pathology²⁹

Indications for Internal Auditory Canal (IAC) MRI (not including brain)

• Unilateral non-pulsatile tinnitus
• Pulsatile tinnitus
• Suspected acoustic neuroma (Schwannoma) or cerebellar pontine angle tumor with any of the following signs and symptoms: unilateral hearing loss by audiometry, headache, disturbed balance or gait, unilateral tinnitus, facial weakness, or altered sense of taste
• Suspected cholesteatoma
• Suspected glomus tumor
• Asymmetric sensorineural hearing loss on audiogram
• Congenital/childhood sensorineural hearing loss suspected to be due to a structural abnormality^61,62,63 (CNVIII, the brain parenchyma, or the membranous labyrinth). CT is the preferred imaging modality for the osseous anatomy and malformations of the inner ear.
• CSF otorrhea (MRI/nuclear cisternography for intermittent leaks, CT for active leaks); there should be a high suspicion or confirmatory CSF fluid laboratory testing (Beta-2 transferrin assay)
• Bell’s Palsy 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 onset⁵⁷

ADDITIONAL ONCOLOGIC INDICATIONS FOR ORBIT/FACE/SINUS/NECK MRI

Known tumor or cancer of skull base, orbits, sinuses, face, tongue, larynx, nasopharynx, pharynx, or salivary glands⁶⁴

• Initial staging³⁸
• Restaging during treatment
• Suspected recurrence or new metastases based on symptoms or examination findings
  • New mass
  • Change in lymph nodes⁶⁵
• 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

Further evaluation of indeterminate findings on prior imaging (unless follow up is otherwise specified within the guideline): 

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification.³⁷
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam.)

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

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Coding Section 

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 Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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

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