Functional magnetic resonance imaging (fMRI) is a noninvasive method for the evaluation of brain activity by detecting associated changes in blood flow. Images are collected while specific activities are performed to assist in the pre-surgical localization of “eloquent” areas such as motor function and speech.
Functional magnetic resonance imaging (fMRI) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Functional MRI for all other applications is considered investigational.
Functional magnetic resonance imaging (fMRI) is considered medically appropriate if ALL of the following criteria are met:
Used as a complementary test in preoperative evaluation for neurosurgery
Individual with refractory epilepsy or brain tumor when the lesion is in close proximity to an eloquent area of the brain (e.g., controlling verbal or motor function)
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We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
The evidence suggests that although bilateral activation patterns in fMRI cannot be conclusively interpreted, fMRI in patients who are to undergo neurosurgery for seizures or brain tumors may help to define eloquent areas, reduce surgical time, and alter treatment decisions.
eviCore healthcare. (2019, February). Head imaging policy. Functional MRI (f-MRI). Retrieved July 16, 2019 from www.evicore.com. (4 articles and/or guidelines reviewed)
Håberg, A., Kvistad, K.A., Unsgård, G., & Haraldseth, O. (2004). Preoperative blood oxygen level dependent functional magnetic resonance imaging in patients with primary brain tumors: clinical application and outcome. Neurosurgery, 54 (4), 902-914. Abstract retrieved July 17, 2019 from PubMed database.
Medina, L.S., Bernal, B., Dunoyer, C., Cervantes, L., Rodriguez, M., Pacheco, E., et al. (2005). Seizure disorders: functional MR imaging for diagnostic evaluation and surgical treatment – prospective study. Radiology, 236 (1), 247-253. Abstract retrieved July 17, 2019 from https://pubs.rsna.org/doi/pdf/10.1148/radiol.2361040690.
Petrella, J.R., Shah, L.M., Harris, K.M., Friedman, A.H., George, T.M., Sampson, J.H., et al. (2006). Preoperative functional MR imaging localization of language and motor areas: effect on therapeutic decision making in patients with potentially resectable brain tumors. Radiology, 240 (3), 793-802. Abstract retrieved July 17, 2019 from PubMed database.
ORIGINAL EFFECTIVE DATE: 4/13/2012
MOST RECENT REVIEW DATE: 8/8/2019
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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