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 (Amitiptyline, Enalapril, Nifedipine, Propranolol, Penicillamine, Sumatriptan, Cisplatin, Triflouperazine, Propylthiouracil). These should be considered prior to advanced imaging to look for a structural cause. 

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
  • If atypical presentation (bilateral, absence of pain, optic nerve hemorrhages, severe visual impairment, lack of response to steroids, poor recovery or recurrence)^14,15
  • If needed to confirm optic neuritis and rule out compressive lesions
• Orbital trauma^16,17
  • 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^18,19
  • 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)²⁰
• Congenital orbital anomalies

Complex strabismus syndromes (with ophthalmoplegia or ophthalmoparesis) to aid in diagnosis, treatment and/or surgical planning^21,22,23

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 disorders²⁴
• 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)^{10,11,12,13,14,15}
  • If needed to confirm optic neuritis and rule out compressive lesions
• Known or suspected neuromyelitis optica spectrum disorder with severe, recurrent, or bilateral optic neuritis²⁵
• 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 pathology²⁶

INDICATIONS FOR FACE/SINUS MRI:

• Rhinosinusitis²⁷
  • Clinical suspicion of fungal infection²⁸
  • Clinical suspicion of orbital or intracranial complications^18,19, 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^27,29
• Anosmia or Dysosmia based on objective testing that is persistent and of unknown origin^30,31,32
• Suspected infection
  • Osteomyelitis (after X-rays)³³
  • Abscess based on clinical signs and symptoms of infection
• Face mass^27,34,35
  • Present on physical exam and remains non-diagnostic after X-ray or ultrasound is completed
  • Known or highly suspected head and neck cancer on examination²⁷
  • Failed 2 weeks of treatment for suspected infectious adenopathy³⁶
• Facial trauma^16,17,37,38
  • Concern for soft tissue injury to further evaluate for treatment or surgical planning³⁹
• 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 > 2min, pain outside trigeminal nerve distribution, progression)^30,40

INDICATIONS FOR FACE/SINUS AND BRAIN MRI COMBINATION STUDIES:

• Anosmia or dysosmia on objective testing that is persistent and of unknown origin^30,32,41
• Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease⁴²
• Trigeminal neuralgia that meets the above criteria^30,40
• 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 pathology²⁶

INDICATIONS FOR NECK MRI:

Suspected tumor or cancer⁴³:

• Suspicious lesions in mouth or throat³⁵
• 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 completed³⁵
  • Mass or abnormality found on other imaging study and needing further evaluation
  • Increased risk for malignancy with one or more of the following findings⁴⁴:
    • 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 adenopathy³⁶
  • 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)⁴³
  • 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)⁴⁵
  • Staging and monitoring for recurrence of known thyroid cancer⁴⁵
  • To assess extent of thyroid tissue when other imaging suggests extension through the thoracic inlet into the mediastinum or concern for airway compression^46,47

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 infection⁴⁸

Other indications for a Neck MRI:

• MR Sialography to evaluate salivary ducts^49,50
• Vocal cord lesions or vocal cord paralysis⁵¹
• Unexplained ear pain when ordered by a specialist with all of the following⁵²
  • 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^53,54
• 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 onset55
• Objective cranial nerve palsy (CN IX-XII) (for evaluation of the extracranial nerve course)^30,56
• Brachial plexopathy if mechanism of injury or EMG/NCV studies are suggestive^57,58

          Note: Chest MRI is preferred study, but neck and/or shoulder (upper extremity) MRI can be ordered 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)^30,56
• 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 pathology²⁶

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 glands

• Initial staging³⁵
• Restaging during treatment
• Suspected recurrence or new metastases based on symptoms or examination findings
  • New mass
  • Change in lymph nodes⁵⁹
• 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

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

 References 

1. Dankbaar JW, van Bemmel AJ, Pameijer FA. Imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis. Insights Imaging . 2015; 6(5):509-518.  
2. American College of Radiology (ACR). ACR Appropriateness Criteria® Cranial Neuropathy. 2017. https://acsearch.acr.org/docs/69509/Narrative
3. American College of Radiology (ACR). ACR Appropriateness Criteria® Plexopathy. 2016. https://acsearch.acr.org/docs/69487/Narrative.
4. American College of Radiology (ACR). ACR Appropriateness Criteria® Neck Mass/Adenopathy 2018a. https://acsearch.acr.org/docs/69504/Narrative/.
5. American College of Radiology (ACR). ACR Appropriateness Criteria® Thyroid Disease. 2018b. https://acsearch.acr.org/docs/3102386/Narrative/.
6. Arunkumar JS, Naik AS, Prasad KC, et al. Role of nasal endoscopy in chronic osteomyelitis of maxilla and zygoma: A case report. Case Med. 2011; Article ID 802964.
7. Behbehani R. Clinical approach to optic neuropathies. Clin Ophthalmol. 2007; 1(3):233-246.
8. Brown RE, Harave S. Diagnostic imaging of benign and malignant neck masses in children – A pictorial review. Quant Imaging Med Surg. 2016 Oct; 6(5):591-604.  
9. Burke CJ, Thomas RH, Howlett D. Imaging the major salivary glands. Br J Oral Maxillofac Surg. 2011; 49(4):261.
10. Consortium of Multiple Sclerosis Centers (CMSC). MRI protocol and clinical guidelines for the diagnosis and follow-up of MS. February 2018.
11. Dankbaar JW, Pameijer FA. Vocal cord paralysis: Anatomy, imaging and pathology. Insights Imagings. December 2014; 5(6):743-751.
12. Dankbaar JW, van Bemmel AJ, Pameijer FA. Imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis. Insights Imaging. 2015; 6(5):509-518.
13. Echo A, Troy JS, Hollier LH. Frontal sinus fractures. Semin Plast Surg. 2010; 24(4):375-382. http://doi.org/10.1055/s-0030-1269766. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3324222/.
14. Fadzil F, Ramli N, Ramli NM. MRI of optic tract lesions: review and correlation with visual field defects. Clin Radiol. 2013 Oct; 68(10):e538-51.
15. Gala F. Magnetic resonance imaging of optic nerve. Indian J Radiol Imaging. 2015 Oct-Dec; 25(4):421-438.
16. Gavito-Higuera J, Mullins CB, Ramos-Duran L, et al. Sinonasal fungal infections and complications: A pictorial review. J Clin Imaging Sci. 2016 Jun 14; 6:23.
17. Gharib H, Papini E, Garber JR, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules – 2016 Update. Endocr Pract. 2016 May; 22(5):622-39.   
18. Hande PC, Talwar I. Multimodality imaging of the orbit. Indian J Radiol Imaging. 2012; 22(3):227-239. http://doi.org/10.4103/0971-3026.107184.
19. Haynes J, Arnold K, Aguirre-Oskins C, et al. Evaluation of neck masses in adults. Am Fam Physician. May 2015; 91(10):698-706. https://www.aafp.org/afp/2015/0515/p698.html.
20. Hata M, Miyamoto K. Causes and prognosis of unilateral and bilateral optic disc swelling. Neuroophthalmology. 2017 Aug; 41(4):187-191.
21. Hoang JK, Vanka J, Ludwig BJ, et al. Evaluation of cervical lymph nodes in head and neck cancer with CT and MRI: Tips, traps, and a systematic approach. Am J Roentgenol. 2013; 200:W17-W25.
22. Hughes MA, Frederickson AM, Branstetter BF, et al. MRI of the trigeminal nerve in patients with trigeminal neuralgia secondary to vascular compression. Am J Roentgenol. 2016; 206:595-600.
23. Kedar S, Ghate D, Corbett JJ. Visual fields in neuro-ophthalmology. Indian J Ophthalmol. 2011 Mar-Apr; 59(2):103-109.
24. Kennedy TA, Corey AS, et al. ACR Appropriateness Criteria Orbits Vision and Visual Loss. J Am Coll Radiol. 2018 May; 15(5S):S116-S131.
25. Khan MA, Rafiq S, Lanitis S, et al. Surgical treatment of primary hyperparathyroidism: Description of techniques and advances in the field. Indian J Surg. 2014; 76(4):308-315.
26. Kirsch CFE, Bykowski J, et al. ACR Appropriateness Criteria Sinonasal Disease. J Am Coll Radiol. 2017 Nov; 14(11S):S550-S559.
27. Koeller KK. Radiologic features of sinonasal tumors. Head Neck Pathol. 2016; 10(1):1-12.
28. Kransdorf MJ, Murphey MD, Wessell DE, et al. American College of Radiology (ACR) Appropriateness Criteria. Expert Panel on Musculoskeletal Imaging: Soft-Tissue Masses. https://acsearch.acr.org/docs/69434/Narrative/. Published 2017.
29. Kuno H, Onaya H, Fujii S, et al. Primary staging of laryngeal and hypopharyngeal cancer: CT, MR imaging and dual-energy CT . (Epub October 27, 2013). Eur J Radiol. January 2014; 83(1):e23-35. https://www.ncbi.nlm.nih.gov/pubmed/24239239
30. Lawson, GR. Sedation of children for magnetic resonance imaging. Archives Dis Childhood. 2000; 82(2).
31. Lee YJ, Sadigh S, Mankad K, et al. The imaging of osteomyelitis. Quant Imaging Med Surg. 2016; 6(2):184-198. http://doi.org/10.21037/qims.2016.04.01. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4858469/.
32. Lin YS, Wu HY, Lee CW, et al. Surgical management of substernal goiters at a tertiary referral centre: A retrospective cohort study of 2,104 patients. Int J Surg. 2016 Mar; 27:46-52.
33. Lin KY, Ngai P, Echegoyen JC. Et. al. Imaging in orbital trauma. Saudi J Ophthalmol. 2012 Oct; 26(4):427-432.
34. Margolin E. Swollen optic nerve: An approach to diagnosis and management. Pract Neurol. 2019 Jun 13. Epub ahead of print.
35. Meyer AC, Kimbrough TG, Finkelstein M, et al. Symptom duration and CT findings in pediatric deep neck infection. Otolaryngol Head Neck Surg. 2009; 140(2):183-186. doi: 10.1016/j.otohns.2008.11.005.
36. Mumtaz S, Jensen MB. Facial neuropathy with imaging enhancement of the facial nerve: A case report. Future Neurol. 2014; 9(6):571-576. doi:10.2217/fnl.14.55.
37. Oh JW, Kim SH, Whang K. Traumatic cerebrospinal fluid leak: Diagnosis and management. Korean J Neurotrauma. 2017; 13(2):63-67.
38. Pakalniskis MG, Berg AD, Policeni BA, et al. The many faces of granulomatosis with polyangiitis: A review of the head and neck imaging manifestations. Am J Roentgenol. 2015; 205:W619-W629.
39. Pakdaman MN, Sepahdari AR, Elkhanary SM. Orbital inflammatory disease: Pictorial review and differential diagnosis. World J Radiol. 2014 Apr 28; 6(4):106-115.
40. Passi N, Degnan AJ, Levy LM. MR imaging of papilledema and visual pathways: Effects of increased intracranial pressure and pathophysiologic mechanisms. Am J Neuroradiol. 2013 May; 34(5):919-924.
41. Piciucchi S, Barone D, Gavelli G, et al. Primary hyperparathyroidism: Imaging to pathology. J Clin Imaging Sci. 2012; 2:59.
42. Pincus DJ, Armstrong MB, Thaller SR. Osteomyelitis of the craniofacial skeleton. Semin Plast Surg. May 2009; 23(2):73-79.
43. Policeni B, Corey AS, Burns J, et al. American College of Radiology (ACR) Appropriateness Criteria. Expert Panel on Neurologic Imaging: Cranial Neuropathy. https://acsearch.acr.org/docs/69509/Narrative/. Published 2017.
44. Prasad S, Galetta SL. Approach to the patient with acute monocular visual loss. Neurol Clin Pract. 2012; 2(1):14-23.
45. Pynnonen MA, Gillespie MB, Roman B, et al. Clinical practice guideline: Evaluation of the Neck Mass in Adults. Otolaryngol Head Neck Surg. 2017; 157(2_suppl):S1.
46. Quesnel AM, Lindsay RW, Hadlock TA. When the bell tolls on Bell's palsy: Finding occult malignancy in acute-onset facial paralysis. Am J Otolaryngol. 2010 Sep-Oct; 31(5):339-42. Epub 2009 Jun 24.
47. Raju N S, Ishwar P, Banerjee R. Role of multislice computed tomography and three-dimensional rendering in the evaluation of maxillofacial injuries. J Oral Maxillofac Radiol. 2017; 5:67-73.
48. Razek AA, Huang BY. Soft Tissue Tumors of the Head and Neck: Imaging-based Review of the WHO Classification. RadioGraphics. 2011; 31:7:1923-1954. http://pubs.rsna.org/doi/pdf/10.1148/rg.317115095.
49. Ren YD, Li XR, Zhang J, et al. Conventional MRI techniques combined with MR sialography on T2-3D-DRIVE in Sjögren syndrome. Int J Clin Exp Med. 2015; 8(3):3974-3982.
50. Romano N, Federici M, Castaldi A. Imaging of cranial nerves: a pictorial overview. Insights Imaging. 2019 Mar 15; 10(1):33. doi:10.1186/s13244-019-0719-5.  
51. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. American Academy of Otolaryngology- Head and Neck Surgery. Clinical Practice Guideline (update): Adult Sinusitis. Otolaryngol Head Neck Surg. 2015; 152(2 Suppl):S1-S39.
52. Rouby C, Thomas-Danquin T, Vigouroux M, et al. The Lyon clinical olfactory test: Validation and measurement of hyposmia and anosmia in healthy and diseased populations. Int J Otolaryngol. 2011; Article ID 203805.
53. Sadun AA, Wang MY. Abnormalities of the optic disc. Handb Clin Neurol. 2011; 102:117-57. doi: 10.1016/B978-0-444-52903-9.00011-X.
54. Salvolini U. Traumatic injuries: Imaging of facial injuries. Eur Radiol. 2002 Jun; 12(6):1253-61. Epub 2002 Apr 24. 
55. Snetty VS, Reis MN, Aulino JM, et al. American College of Radiology (ACR) Appropriateness Criteria. Expert Panel on Neurologic Imaging: Head trauma. https://acsearch.acr.org/docs/69481/Narrative/. Published 2015.
56. Srikajon J, Siritho S, Ngamsombat C, et al. Differences in clinical features between optic neuritis in neuromyelitis optica spectrum disorders and in multiple sclerosis. Mult Scler J Exp Transl Clin. 2018 Aug 11; 4(3):2055217318791196. doi: 10.1177/2055217318791196.
57. Stalcup ST, Tuan AS, Hesselink JR. Intracranial causes of ophthalmoplegia: The visual reflex pathways. RadioGraphics. 2013; 33(5).
58. Sun JK, LeMay DR. Imaging of facial trauma. Neuroimaging Clin N Am. 2002 May; 12(2):295-309.
59. Sung EK, Nadgir RN, Fujita A, et al. Injuries of the globe: What can the radiologist offer? RadioGraphics. 2014; 34(3).
60. Tharin BD, Kini JA, York GE, et al. Brachial plexopathy: A review of traumatic and nontraumatic causes. AJR Am J Roentgenol. 2014; 202(1):W67.
61. Voss E, Raab P, Trebst C, et al. Clinical approach to optic neuritis: Pitfalls, red flags and differential diagnosis. Ther Adv Neurol Disord. 2011; 4(2):123-134.
62. Wai K, Wang T, Lee E, et al. Management of persistent pediatric cervical lymphadenopathy. Arch Otorhinolaryngol Head Neck Surg. 2020; 4(1):1. DOI: 10.24983/scitemed.aohns.2020.00121.
63. Wingerchuk DM, Banwell B, Bennett JL, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology. 2015; 85:177.
64. Zaghouani H, Slim I, Zina NB, et al. Kallmann syndrome: MRI findings. Indian J Endocrinol Metab. 2013; 17(Suppl 1):S142–S145. doi:10.4103/2230-8210.119536.

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" 

History From 2019 Forward