UTILIZATION MANAGEMENT POLICY AND PROCEDURE MANUAL

Transcription

1 University of Florida, Pediatric Integrated Care System UTILIZATION MANAGEMENT POLICY AND PROCEDURE MANUAL Policy: Program(s): Approval Criteria for Neuroimaging of Headaches Title XIX and Title XXI Effective Date: February 22, 2013 Approved by: Title Name Signature Medical Director Executive Director Don Fillipps, MD Leslie Herndon, MBA, CPC, CMPE Dates Revised 11/6/2017 Ped-I-Care Approved 2/28/2013, 11/17/2017 Responsible Parties: Medical Directors and Assistant Director for Utilization Management Contract(s): 2014 Medicaid MMA Contract and 2013 Title XXI Contract Contract Section(s): Title XIX VII. G. 1. a. (4), b. Title XXI VII. 6. a. Purpose To provide consistency in the review and authorization of neuroimaging for headaches. Policy 1. Ped-I-Care requires prior authorization of certain services. 2. Documentation of medical necessity must be provided prior to approval of the service request. Procedures Approval Criteria for Neuroimaging of Headaches Page 1 of 5

2 1. Criteria for Approval a. Obtaining a neuroimaging study on a routine basis is not indicated in children with recurrent headaches and a normal neurological examination. b. Neuroimaging should be considered for approval in children with abnormal neurological examination (e.g., focal findings, signs of increased intracranial pressure, significant alteration of consciousness), the coexistence of seizures or both. c. Neuroimaging should be considered for approval in children in whom there are historical features to suggest recent onset of severe headache, change in the type of headache, or if there are associated features that suggest neurological dysfunction. 2. Supporting Information a. Headache characteristics (1) Not supported for approval: i. Isolated headache unaccompanied by neurological signs, presence of a seizure or supporting patient historical data. (2) Supported for approval: i. Symptoms or neurological signs suggesting intracranial tumor ii. Headaches that awakened the child from sleep or occur on arising iii. Intense, prolonged, and incapacitating headaches with an absent family history for migraine iv. Headaches increasing in frequency, duration, and intensity v. Headaches accompanied by vomiting 3. Literature Reference Information a. Annual incidence of brain tumor in the pediatric age group approximates 0.003% b. One Class II report analyzed the cost effectiveness of the diagnostic imaging strategy in children with headaches who are suspected of having a brain tumor. Patients were stratified into low, intermediate, and high-risk groups based on clinical predictors obtained from medical history and physical examinations. The probability of brain tumor in the three groups was calculated to be 0.01% for low, 0.4% for intermediate, and 4% for high-risk groups. The highest yield and most reasonable cost effectiveness was found only in the high risk group-those children with headache for less than six months and at least one other predictor of a "surgical space occupying lesion included sleep-related headache, vomiting, confusion, absence of visual aura, absence of a family history of migraine, and abnormal neurological examination (4). c. Headaches with positive neurological signs or symptoms: Approval Criteria for Neuroimaging of Headaches Page 2 of 5

3 (1) Studies show that nearly all children with intracranial tumors have symptoms of numerological signs accompanying headaches (3, 4, 5). (2) 94% of children with brain tumors had abnormal neurological findings at diagnosis and 60% have papilledema (5). (3) Papilledema, nystagmus, and gait disturbances were identified as univariant predictors of brain tumor. Confusion and other assorted abnormal neurological findings were multivariate predictors of brain tumors (4). d. Supporting patient historical data: specific patient historical data or headache characteristics that are associated with intracranial pathology: (1) Headaches that awakened the child from sleep or occur on arising appear to have clinical significance (3). (2) Intense, prolonged, and incapacitating headaches with an absent family history for migraine may indicate an underlying pathology. (3) Patients with headaches increasing in frequency, duration, and intensity may benefit from imaging (3). (4) Vomiting accompanied headaches in 78% of patients was predictive of a pathological process (4). e. Migraine with/without aura (1) 17% of patients with migraine headaches had an accompanying aura with symptoms that include: nausea, vomiting, abdominal pain, and disturbances of vision (6, 7). (2) Clinicians can have difficulty distinguishing the first, second, or third migraine headache from headache caused by a brain tumor or other intracranial abnormality (8). A clue in differentiating these headaches may relate to transient neurological findings versus persistent findings in tumor headaches. f. Complicated migraines with focal neurologic findings (1) Signs and symptoms of complicated migraines with focal neurologic findings cannot be discriminated from similar presentations related to intracranial neoplasms and imaging is recommended (4, 6). g. Sinogenic headache (1) In children who present with severe and persistent headache as the dominant feature of sinusitis, imaging may be warranted. Clinical signs suggesting intracranial abnormality include high fever, confusion, and change in mental status with and without focal signs (9, 10, 11, 12). h. Headache with fever or known underlying disease (1) In high-risk groups, the presence of a severe headache may indicate significant intracranial pathology. It would be appropriate to consider a lower threshold for imaging in this population. Approval Criteria for Neuroimaging of Headaches Page 3 of 5

4 (2) Children with underlying disease-immunocompromised patients, children with known neoplasms, sickle cell patients, and patients with coagulopathy or hypertension-are predisposed to intracranial pathology. References 1. American Academy of Neurology, April 28, 2010, Practice parameter. 2. American College of Radiology Appropriateness Criteria-Headache (ACR), Honig PJ, Charney EB. Children with brain tumor headaches. Distinguishing features predictive of a pathological process. Am J Dis Child 1982: 136(2): Medina LS, Kuntz KM, Pomeroy SL. Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies. Pediatrics 2001; 108: Medina LS, Pinter JD, Zurakowski D, Davus RG, Kuban K, Barnes PD. Children with headache: clinical predictors of surgical space occupying lesions and the role of neuroimaging. Radiology 1997; 202(3): The epidemiology of headache among children with brain tumor. Headache in children with brain tumors. The Childhood Brain Tumor Consortium. J Neurooncol 1991; 10(1): Barlow CF. Headaches and migraine in childhood. Clinics in Developmental Medicine. No. 91. Philadelphia,Pa; JB Lippincott; 1984: Menkes JH. Textbook of Child Neurology. Baltimore, MD: Williams & Wilkins.; 1995: Iurlao S, Beghi E, Massetto N, et al. Does headache represent a clinical marker in early diagnosis of cerebral venous thrombosis? A prospective multicentric study. Neurol Sci 2004:25 Suppl 3: S Becker LA, Green LA, Beaufait D, Kirk J, Froom J, Freeman WL. Use of CT scans for the investigation of headache: a report from ASPN, Part 1. J. Fam pract 1993; 37(2): Chalstrey S, Pfleiderer AG, Moffat DA. Persisting incidence and mortality of sinogenic cerebral abscess: a continuing reflection of late clinical diagnosis. J R Soc Med 1991; 84(4): Maniglia AJ, Goodwin WJ, Arnold JE, Ganz E. Intracranial abscesses secondary to nasal, sinus, and orbital infections in adults and children. Arch Otolalaryngol Head Neck Surg 1989; 115(12): Stone CK, Thomas SH. Bilateral epidural empyemas in an adolescent. Am J Emerg Med 1994; 12(4): Approval Criteria for Neuroimaging of Headaches Page 4 of 5

5 These recommendations are from the American Academy of Neurology, Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. (April 28, 2010); and the American College of Radiology (ACR) Appropriateness Criteria (2008). Approval Criteria for Neuroimaging of Headaches Page 5 of 5