Medical Policy



Subject: Magnetic Resonance Spectroscopy (MRS)
Document #: RAD.00022 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017

Description/Scope

This document addresses magnetic resonance spectroscopy (MRS) which is a non-invasive technique that can be used to measure the concentrations of different chemical components within tissues. MRS has been studied most extensively in a variety of brain pathologies and may be performed as an adjunct to magnetic resonance imaging (MRI). While an MRI provides an anatomic image of the brain, MRS provides a functional image related to underlying dynamic physiology.  

Position Statement

Medically Necessary:

Magnetic resonance spectroscopy (MRS) is considered medically necessary when used to:

Investigational and Not Medically Necessary:

Magnetic resonance spectroscopy (MRS) is considered investigational and not medically necessary for all applications not listed above, including, but not limited to:

Rationale

The non-invasive distinction between benign and malignant disease in the brain is an important diagnostic step that determines the necessity of a brain biopsy.  One common scenario is the distinction between recurrent tumor and radiation necrosis.  If a non-invasive study can accurately identify a benign process, the individual may be spared a brain biopsy, (that is, high negative predictive value).  Conversely, if a study can accurately identify a malignant process, the individual could initiate therapy without a confirmatory biopsy.  It is thought that the diagnostic performance of magnetic resonance imaging (MRI) and positron emission tomography (PET) is inadequate to influence biopsy decisions, and thus, there has been considerable interest in magnetic resonance spectroscopy (MRS), as a non-invasive imaging alternative.  The literature regarding MRS in individuals with suspected brain tumors is dominated by case series of heterogeneous subjects.  These studies suggest that MRS can appropriately influence biopsy decisions.  Additional systematic reviews and meta-analyses have added to the current knowledge base regarding the utility of MRS in the evaluation of brain lesions (Chen, 2016; Chuang, 2016; Wang, 2016).  Despite some limitations noted in the published evidence and the need for larger well-designed robust trials, the currently available evidence is sufficient to demonstrate that MRS is an effective technique for the management of brain lesions.

There is inadequate data regarding other applications of MRS.  Concerning prostate cancer imaging with MRS, the available published evidence includes a meta-analysis conducted in 2008 of the accuracy of prostate cancer studies which use MRS as a diagnostic tool.  Seven studies of MRS as a method to diagnose prostate cancer were included.  The pooled weighted sensitivity was 0.82 (95% confidence interval [CI], 0.73-0.89); specificity, 0.68 (95% CI, 0.58-0.76); and the area under the curve, 83.40.  All of these results were based on a cutoff for identifying "definitive" tumor of 0.85 for the ratio of (choline + creatine) to citrate.  The authors concluded that, as a new method in the diagnosis of prostate cancer, MRS has a better applied value compared to other common modalities but that large scale randomized controlled trials are needed to fully evaluate its clinical value (Wang, 2008).  

In 2010, Jambor assessed the ability of (11)C-acetate PET/CT, MRI, and proton MR spectroscopy ((1)H-MRS) to image localized prostate cancer and detect its aggressiveness, using qualitative and quantitative approaches.  Twenty-one subjects with untreated localized prostate cancer, diagnosed using transrectal ultrasound-guided biopsy, were prospectively enrolled.  Cancer laterality was based on the percentage of cancer and the highest Gleason score determined from biopsies.  In addition to PET/CT, 3-dimensional (1)H-MRS of the entire prostate volume using a quantitative approach was performed.  The imaging and histologic findings of 8 subjects undergoing subsequent prostatectomy were compared on a sextant level.  For each lobe and sextant, standardized uptake values (SUVs) and (choline + creatine + polyamines)-to-citrate (CCP/C) ratios were obtained from (11)C-acetate PET/CT and (1)H-MRS, respectively.  The visual and quantitative findings on PET/CT and MRI data were compared with cancer laterality and aggressiveness based on the Gleason score and with prostate-specific antigen (PSA) velocity and international risk group classification.  The sensitivity, specificity, and accuracy, on a lobar level using visual analysis of (11)C-acetate PET/CT were 80%, 29%, 71%, respectively, and 89%, 29%, 79%, respectively, using contrast-enhanced MRI.  The sensitivity and accuracy of (11)C-acetate PET/CT decreased to 64% and 63% and specificity increased to 62% when sextant analysis was performed.  The agreement between prostate cancer laterality based on biopsy findings and visual interpretation of (11)C-acetate PET/CT and contrast-enhanced MRI was similar at 71%.  The dominant-lesion SUVs or CCP/C values were not associated with histologically determined prostate cancer aggressiveness, nor did PSA velocity correlate with the SUV or CCP/C values from the entire gland.  The authors concluded that (11)C-acetate PET/CT, MRI, and (1)H-MRS enable detection of localized prostate cancer with comparable and limited accuracy but fail to provide information on cancer aggressiveness (Jambor, 2010).  Additional small studies of MRS in prostate cancer evaluation also concluded that larger, well-designed studies are needed to clarify the role of MRS in prostate cancer diagnosis and evaluation of post-treatment recurrence and to demonstrate its impact on clinical outcomes (Panebianco, 2010; Panebianco, 2012; Perdona, 2011; Sciarra, 2010).

In the case of neurological disorders such as Alzheimer's disease, Parkinson's disease, and multiple sclerosis, while MRS has demonstrated changes in neurochemistry, no studies were identified in the scientific literature that positively correlated these changes with clinical findings, established the sensitivity or specificity of MRS in these disorders, or compared the diagnostic or prognostic performance of MRS to that of established imaging techniques and other forms of testing.  The clinical utility of MRS, in terms of its value in clinical decision-making or improvement in health outcomes, as a result of management decisions based on MRS findings, has not been demonstrated, to date, for any conditions beyond brain tumor imaging (Baltzer, 2013; Cen, 2014; Shiino, 2012; Thayyil, 2010; Wang, 2015).

Background/Overview

MRS is a non-invasive technique that can be used to measure the concentrations of different chemical components within tissues.  The technique is based on the same physical principles as magnetic resonance imaging (MRI), that is the detection of energy exchange between external magnetic fields and specific nuclei within atoms.  With MRI, this energy exchange, measured as a radiofrequency signal, is then translated into the familiar anatomic image by assigning different gray values, according to the strength of the emitted signal.  The principal difference between MRI and MRS is that in MRI the emitted radiofrequency is based on the spatial position of nuclei, while MRS detects the chemical composition of the scanned tissue.  The information produced by MRS is displayed graphically, as a spectrum with peaks consistent with the various chemicals detected.  MRS may be performed as an adjunct to MRI.  An MRI image is first generated, and then MRS spectra are developed at the site of interest, termed the voxel.  While an MRI provides an anatomic image of the brain, MRS provides a functional image related to underlying dynamic physiology.  MRS can be performed with existing MRI equipment that has been modified with additional software and hardware.  MRS has been studied most extensively in a variety of brain pathologies.

Definitions

Abscess: A circumscribed collection of infectious material, such as pus, which is frequently associated with swelling and inflammation.

Magnetic resonance spectroscopy (MRS): A non-invasive imaging technique that can be used to measure concentrations of different chemicals in body tissues, aiding in the detection and discrimination of various cystic and tumor masses.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT  
76390 Magnetic resonance spectroscopy
   
ICD-10 Diagnosis  
C70.0 Malignant neoplasm of cerebral meninges
C71.0-C71.9 Malignant neoplasm of brain
C79.31-C79.32 Secondary malignant neoplasm of brain, cerebral meninges
D32.0 Benign neoplasm of cerebral meninges
D33.0-D33.3 Benign neoplasm of brain, cranial nerves
D42.0 Neoplasm of uncertain behavior of cerebral meninges
D43.0-D43.3 Neoplasm of uncertain behavior of brain, cranial nerves
D49.6 Neoplasm of unspecified behavior of brain
G00.0-G03.9 Meningitis
G04.00-G05.4 Encephalitis, myelitis and encephalomyelitis
G06.0 Intracranial abscess and granuloma
G06.2 Extradural and subdural abscess, unspecified
G07 Intracranial and intraspinal abscess and granuloma in diseases classified elsewhere
G93.6 Cerebral edema
G93.81-G93.89 Other specified disorders of brain
I67.89 Other cerebrovascular disease [radiation necrosis]
T66.XXXS Radiation sickness, unspecified, sequela
Z85.841 Personal history malignant neoplasm of brain

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

References

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Government Agency, Medical Society, and Other Authoritative Publications:

  1. Alberta Health Services. High Field Magnetic Resonance Spectroscopy Imaging for Follow Up of Prostate Cancer Post Brachytherapy Implantation. NCT00126854. Last updated February 24, 2016. Available at: http://www.clinicaltrials.gov/ct2/show/NCT00126854?term=MR+spectroscopy&rank=7. Accessed on March 22, 2017.
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  6. Centers for Medicare and Medicaid Services. National Coverage Determination: Magnetic Resonance Spectroscopy (MRS). NCD #220.2.1. Effective September 10, 2004. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=287&ncdver=1&bc=BAAAgAAAAAAA&. Accessed on March 22, 2017.
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  8. Frohman EM, Goodin DS, Calabresi PA, et al.; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. The utility of MRI in suspected MS: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2003; 61(5):602-611.
  9. Hailey D. Magnetic resonance spectroscopy (MRS) in the management of localized prostate cancer. Ottawa: Canadian Coordinating Office for Health Technology Assessment (CCOHTA) 2003. Available at: http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?View=Full&ID=32003001149. Accessed on March 22, 2017.
  10. Jordan H, Bert R, Chew P, et al. Agency for Healthcare Research and Quality (AHRQ). Magnetic Resonance Spectroscopy for Brain Tumors Technology Assessment. Tufts-New England Medical Center. April 24, 2003. No. 290-02-0022. Rockville, MD. Available at: http://www.cms.hhs.gov/determinationprocess/downloads/id17TA.pdf. Accessed on March 22, 2017.
  11. Memorial Sloan-Kettering Cancer Center and National Cancer Institute. Monitoring Response to Neoadjuvant Chemotherapy by the Use of Breast Proton MR Spectroscopy. NCT00580086. Last updated December 23, 2009. Available at:  http://www.clinicaltrials.gov/ct2/show/NCT00580086?term=MR+spectroscopy&rank=1.  Accessed on March 22, 2017.
  12. Ment LR, Bada HS, Barnes P, et al. Practice parameter: Neuroimaging of the neonate: report of the Quality Standards Subcommittee of the America Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002; 58(12):1726-1738.
  13. Mowatt G, Scotland G, Boachie C, et al. The diagnostic accuracy and cost-effectiveness of magnetic resonance spectroscopy and enhanced magnetic resonance imaging techniques in aiding the localization of prostate abnormalities for biopsy: a systematic review and economic evaluation. Health Technol Assess. 2013; 17(20):vii-xix, 1-281.
  14. National Cancer Institute (NCI), American College of Radiology Imaging Network. Magnetic Resonance Imaging and Magnetic Resonance Spectroscopic Imaging in Diagnosing the Extent of Disease in Patients With Prostate Cancer.  NLM Identifier: NCT00032058. Last updated on February 18, 2011. Available at:   http://www.clinicaltrials.gov/ct2/show/NCT00032058?term=MR+Imaging+and+MR+spectroscopic+Imaging+of+Prostate+Cancer+Prior+to+Radical+Prostatectomy&rank=1. Accessed on March 22, 2017.
  15. NCCN Clinical Practice Guidelines in Oncology. © 2017. National Comprehensive Cancer Network, Inc. For additional information: http://www.nccn.org/index.asp. Accessed on March 22, 2017.
    • Central Nervous System Cancers (V1.2016). Revised July 25, 2016.
    • Prostate Cancer (V2.2017). Revised February 21, 2017.
  16. New York University School of Medicine. Image Guided Therapy in the Treatment of Gliomas.  NLM Identifier:  NCT01263821. Last updated September 8, 2016.  Available at:  http://www.clinicaltrials.gov/ct2/show/NCT01263821?term=NCT01263821&rank=1. Accessed on March 22, 2017.
  17. Washington University School of Medicine.  MRI (Including Spectroscopy and Fat-Saturations and Diffusion-Weighted Imaging) in Cervical Cancer.  NCT01060033. Last updated September 5, 2014. Available at: http://www.clinicaltrials.gov/ct2/show/NCT01060033?term=NCT01060033&rank=1. Accessed on March 22, 2017.
Websites for Additional Information
  1. American College of Radiology (ACR). Available at:  www.ACR.org. Accessed on March 22, 2017.
Index

Magnetic Resonance Spectroscopy
MRS
NMR Spectroscopy

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History

Status

Date

Action

Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. 
Reviewed 05/03/2017 Hematology/Oncology Subcommittee review. Updated the formatting in the Position Statement section. The Rationale and References sections were updated.
Reviewed 05/05/2016 MPTAC review. 
Reviewed 05/04/2016 Hematology/Oncology Subcommittee review. References were updated. Removed ICD-9 codes from Coding section.
Reviewed 05/07/2015 MPTAC review. 
Reviewed 05/06/2015 Hematology/Oncology Subcommittee review. References were updated.
Reviewed 05/15/2014 MPTAC review. 
Reviewed 05/14/2014 Hematology/Oncology Subcommittee review. Coding and References sections were updated.
Reviewed 05/09/2013 MPTAC review. 
Reviewed 05/08/2013 Hematology/Oncology Subcommittee review. Updated the Rationale and Reference sections.
Revised 05/10/2012 MPTAC review. Prostate cancer imaging was added to the list of indications considered investigational and not medically necessary. The Rationale and References were updated.
Reviewed 05/19/2011 MPTAC review. 
Reviewed 05/18/2011 Hematology/Oncology Subcommittee review. Updated Reference section.
Reviewed 05/13/2010 MPTAC review.  Updated Reference section.
Reviewed 05/12/2010 Hematology/Oncology Subcommittee review.
Reviewed 05/21/2009 MPTAC review.  Updated Reference section.
Reviewed 05/20/2009 Hematology/Oncology Subcommittee review.
Reviewed 05/15/2008 MPTAC review.  References were updated.
  02/21/2008 The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 Medical Policy and Technology Assessment Committee (MPTAC) meeting.
Reviewed 05/17/2007 MPTAC review. Coding and References were updated. 
Reviewed 06/08/2006 MPTAC review. References were updated.
  11/21/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised 07/14/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.    
Pre-Merger Organizations

Last Review Date

Document Number

Title

 
Anthem, Inc.

04/28/2005

RAD.00022 Magnetic Resonance Spectroscopy  
WellPoint Health Networks, Inc.

04/28/2005

4.01.13 Magnetic Resonance Spectroscopy