MAGNETIC RESONANCE (MR) NEUROGRAPHY

Transcription

1 MAGNETIC RESONANCE (MR) NEUROGRAPHY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Medical Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as Description defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as Criteria defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Medical Coverage Guidelines are subject to change as new information becomes available. For purposes of this Medical Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other trademarks and service marks contained in this guideline are the property of their respective owners, which are not affiliated with BCBSAZ. Description: Magnetic resonance (MR) neurography has been investigated as a tool to diagnose nerve disorders. The technology involves modifying conventional MR imaging to enable high resolution longitudinal and cross sectional images of peripheral nerves in order to view nerve morphology. This may or may not require specialized MRI equipment or software. Brachial plexus exams require specialized coils. Extremity MR neurography may also be referred to as MRI of the extremity. O docx Page 1 of 6

2 Criteria: MR neurography is considered experimental or investigational for all diagnoses based upon: 1. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and 2. Insufficient evidence to support improvement of the net health outcome, and 3. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives. Resources: Literature reviewed 06/07/17. We do not include marketing materials, poster boards and nonpublished literature in our review. 1. Bao H, Wu C, Wang S, et al. Diffusion-weighted magnetic resonance neurography for the diagnosis of carpal tunnel syndrome: a pilot study. Clinical radiology. Feb 2017;72(2): Baumer P, Kele H, Kretschmer T, et al. Thoracic outlet syndrome in 3T MR neurography-fibrous bands causing discernible lesions of the lower brachial plexus. Eur Radiol. Mar 2014;24(3): Birnbaum J, Duncan T, Owoyemi K, Wang KC, Carrino J, Chhabra A. Use of a novel highresolution magnetic resonance neurography protocol to detect abnormal dorsal root Ganglia in Sjogren patients with neuropathic pain: case series of 10 patients and review of the literature. Medicine (Baltimore). May 2014;93(3): Bucknor MD, Steinbach LS, Saloner D, Chin CT. Magnetic resonance neurography evaluation of chronic extraspinal sciatica after remote proximal hamstring injury: a preliminary retrospective analysis. J Neurosurg. May : Burge AJ, Gold SL, Kuong S, Potter HG. High-resolution magnetic resonance imaging of the lower extremity nerves. Neuroimaging Clin N Am. Feb 2014;24(1): Chappell KE, Robson MD, Stonebridge-Foster A, et al. Magic angle effects in MR neurography. AJNR Am J Neuroradiol Mar 2004;25(3): Chhabra A, Wadhwa V, Thakkar RS, Carrino JA, Dellon AL. Recurrent ulnar nerve entrapment at the elbow: Correlation of surgical findings and 3-Tesla magnetic resonance neurography. Can J Plast Surg. Fall 2013;21(3): O docx Page 2 of 6

3 Resources: (cont.) 8. Delaney H, Bencardino J, Rosenberg ZS. Magnetic resonance neurography of the pelvis and lumbosacral plexus. Neuroimaging Clin N Am. Feb 2014;24(1): Filler AG, Kliot M, Howe FA, et al. Application of magnetic resonance neurography in the evaluation of patients with peripheral nerve pathology. J Neurosurg Aug 1996;85(2): Fisher S, Wadhwa V, Manthuruthil C, Cheng J, Chhabra A. Clinical impact of magnetic resonance neurography in patients with brachial plexus neuropathies. The British journal of radiology. Nov 2016;89(1067): Freund W, Brinkmann A, Wagner F, et al. MR neurography with multiplanar reconstruction of 3D MRI datasets: an anatomical study and clinical applications. Neuroradiology Apr 2007;49(4): Fritz J, Chhabra A, Wang KC, Carrino JA. Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome. Neuroimaging Clin N Am. Feb 2014;24(1): Grant GA, Goodkin R, Maravilla KR, Kliot M. MR neurography: diagnostic utility in the surgical treatment of peripheral nerve disorders. Neuroimaging Clin N Am Feb 2004;14(1): Lewis AM, Layzer R, Engstrom JW, Barbaro NM, Chin CT. Magnetic resonance neurography in extraspinal sciatica. Arch Neurol Oct 2006;63(10): Mizuma A, Kijima C, Nagata E, Takizawa S. A Case of Suspected Breast Cancer Metastasis to Brachial Plexus Detected by Magnetic Resonance Neurography. Case reports in oncology. May- Aug 2016;9(2): Pham M, Baumer P, Meinck HM, et al. Anterior interosseous nerve syndrome: fascicular motor lesions of median nerve trunk. Neurology. Feb ;82(7): Pham M, Baumer T, Bendszus M. Peripheral nerves and plexus: imaging by MR-neurography and high-resolution ultrasound. Curr Opin Neurol. Aug 2014;27(4): Raphael DT, McIntee D, Tsuruda JS, Colletti P, Tatevossian R. Frontal slab composite magnetic resonance neurography of the brachial plexus: implications for infraclavicular block approaches. Anesthesiology Dec 2005;103(6): O docx Page 3 of 6

4 Resources: (cont.) 19. Review EC. Neuroradiology. 08/08/ Vaeggemose M, Pham M, Ringgaard S, et al. Magnetic Resonance Neurography Visualizes Abnormalities in Sciatic and Tibial Nerves in Patients with Type 1 Diabetes and Neuropathy. Diabetes. Apr Wadhwa V, Hamid AS, Kumar Y, Scott KM, Chhabra A. Pudendal nerve and branch neuropathy: magnetic resonance neurography evaluation. Acta radiologica (Stockholm, Sweden : 1987). Jun 2017;58(6): Wolf M, Baumer P, Pedro M, et al. Sciatic nerve injury related to hip replacement surgery: imaging detection by MR neurography despite susceptibility artifacts. PLoS One. 2014;9(2):e Yamashita R, Isoda H, Arizono S, et al. Selective visualization of pelvic splanchnic nerve and pelvic plexus using readout-segmented echo-planar diffusion-weighted magnetic resonance neurography: A preliminary study in healthy male volunteers. European journal of radiology. Jan 2017;86: O docx Page 4 of 6

5 Non-Discrimination Statement: Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call (602) for Spanish and (877) for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ , (602) , TTY/TDD (602) , crc@azblue.com. You can file a grievance in person or by mail or . If you need help filing a grievance BCBSAZ s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Multi-Language Interpreter Services: O docx Page 5 of 6

6 Multi-Language Interpreter Services: (cont.) O docx Page 6 of 6