Magnetic Resonance Spectroscopy (MRS) Clinical Policy Bulletin
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Defines Aetna's medical necessity and experimental/investigational determinations for magnetic resonance spectroscopy (MRS), lists covered and not-covered CPT/HCPCS and ICD-10 codes, and provides background evidence and guidance. This extraction covers Part 1 of 5 of the policy.
No material clinical or coverage changes; policy has has_material_change=false and no changes listed.
Coverage Summary
Scope: This policy defines Aetna's determinations of medically necessary and experimental/investigational (not medically necessary) uses of magnetic resonance spectroscopy (MRS), and lists covered and not-covered CPT and ICD-10 codes and guidance for documentation and use. Coverage stance: mixed (some indications are medically necessary; others are experimental/investigational). Background (brief): MRS is a non-invasive NMR technique used to evaluate metabolic changes in the brain and other organs; the MRS probe accessory has FDA 510(k) clearance, but the clinical role and impact on outcomes remain unestablished because of limited high-quality evidence.
Metadata: Effective 1998-03-05; Last review 2023-04-11; Next review 2024-02-08.
Medical Necessity — Covered and Not Covered Criteria
Medically Necessary
Aetna considers magnetic resonance spectroscopy (MRS) medically necessary for the following indications:
ALL of the following
- Assessing prognosis in hypoxic ischemic encephalopathy
- Distinguishing low grade from high grade gliomas
- Evaluate a brain lesion of indeterminate nature when the MRS findings will be used to determine whether biopsy/resection can be safely postponed
- Distinguishing recurrent brain tumor from radiation-induced tumor necrosis
Diagnosis and monitoring of metabolic disorders (ONE of)
- Canavan disease
- Creatine deficiency
- Nonketotic hyperglycinemia
- Maple Syrup Urine disease
Diagnosis of leukodystrophies and related disorders (ONE of)
- Metachromatic leukodystrophy (MCL)
- Pelizaeus-Merzbacher disease (PMD)
- Hypomyelination and Congenital Cataract
- Globoid Cell Leukodystrophy (Krabbe disease)
- X-linked adrenoleukodystrophy (X-ALD, CALD)
- Mitochondrial disorders (e.g. Leigh’s syndrome, Kearns-Sayre syndrome, MELAS, et al)
- Alexander disease (ALX, AXD, demyelinogenic leukodystrophy)
- Megalencephalic leukoencephalopathy with subcortical cysts
- Vanishing White Matter disease (Leukoencephalopathy with vanishing white matter, CACH syndrome, CACH/VWM)
- Note: MRS is considered medically necessary for disease monitoring of these diagnoses when recent MRI findings are inconclusive and a change in therapy is being considered.
Experimental and Investigational (Not Medically Necessary)
MRS is considered experimental and investigational for all other indications (not all-inclusive list):
ANY of the following
- Breast cancer
- Cerebrovascular diseases/disorders/injuries
- Dementia and movement disorders (e.g., Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia, Huntington disease, motor neuron disease, normal-pressure hydrocephalus, Parkinson disease/Parkinsonian syndromes, vascular dementia)
- Dermatomyositis
- Detection and quantification of hepatic steatosis in living liver donors
- Detection of central nervous system involvement in individuals with rheumatic autoimmune diseases
- Detection of esophageal squamous cell carcinoma
- Diagnosis of mesial temporal sclerosis
- Differentiation of primary central nervous system lymphoma (PCNSL) from other focal brain lesions
- Epilepsy (including juvenile myoclonic epilepsy, and temporal lobe epilepsy)
- Evaluation of hepatic encephalopathy
- Evaluation of migraine pathophysiology and identification of biomarkers in migraine
- Evaluation of post-traumatic stress disorder
- Head trauma
- Identification of metabolomic profile in individuals with idiopathic intracranial hypertension
- Low back pain
- Lyme neuroborreliosis
- Monitoring hepatocellular carcinoma and liver cirrhosis development
- Mucopolysaccharidosis
- Multiple sclerosis
- Polymyositis
- Prediction of neurodevelopmental impairment in preterm neonates
- Prognosis of consciousness recovery in individuals with vegetative state
- Prostate cancer
- Psychiatric disorders (e.g., ADHD, autism spectrum disorders, bipolar disorder, depression, emotional dysregulation, mood disorders, obsessive-compulsive disorder, psychosis, schizophrenia)
- Radiation encephalopathy
- Sport-related concussion
- Substance use disorders
- Traumatic brain injury
Coding
| 76390 | Magnetic resonance spectroscopy |
| 0609T | Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); acquisition of single voxel data, per disc, on biomarkers (ie, lactic acid, carbohydrate, alanine, laal, propionic acid, proteoglycan, and collagen) in at least 3 discs |
| 0610T | Transmission of biomarker data for software analysis |
| 0611T | Postprocessing for algorithmic analysis of biomarker data for determination of relative chemical differences between discs |
| 0612T | Interpretation and report |
| C71.0 - C71.9 | Malignant neoplasm of brain [not covered for differentiating primary central nervous system lymphoma (PCNSL) from other focal brain lesions] |
| C78.31 | Secondary malignant neoplasm of brain [not covered for differentiating primary central nervous system lymphoma (PCNSL) from other focal brain lesions] |
| D33.0 - D33.2 | Benign neoplasm of brain [not covered for differentiating primary central nervous system lymphoma (PCNSL) from other focal brain lesions] |
| D43.0 - D43.2 | Neoplasm of uncertain behavior of brain [not covered for differentiating primary central nervous system lymphoma (PCNSL) from other focal brain lesions] |
| D49.6 | Neoplasm of unspecified behavior of brain [not covered for differentiating primary central nervous system lymphoma (PCNSL) from other focal brain lesions] |
| E71.0 | Maple Syrup Urine disease |
| E71.2 | Disorder of branched-chain amino-acid metabolism, unspecified [Creatine deficiency] |
| E71.520 - E71.529 | X-linked adrenoleukodystrophy |
| E72.51 | Nonketoic hyperglycinemia |
| E75.23 | Krabbe disease |
| A69.20 - A69.29 | Lyme disease |
| C15.3 - C15.9 | Malignant neoplasm of esophagus |
| C22.0 - C22.9 | Malignant neoplasm of liver and intrahepatic bile ducts |
| C50.011 - C50.929 | Malignant neoplasm of breast (male and female) |
| C61 | Malignant neoplasm of prostate |
| C72.9 | Malignant neoplasm of central nervous system, unspecified [Primary central nervous system (CNS) lymphoma] |
| C79.49 | Secondary malignant neoplasm of spinal cord |
| C79.81 | Secondary malignant neoplasm of breast |
| C79.82 | Secondary malignant neoplasm of genital organs [prostate] |
| D05.00 - D05.92 | Carcinoma in situ of breast |
Provider Actions & Documentation Requirements
Documentation for medically necessary indications
Documentation must support the specific diagnosis (one of the listed covered indications). For disease monitoring, recent MRI findings must be inconclusive and a change in therapy is being considered.
Background and Evidence Summary
MRS (also called NMR spectroscopy) is a non-invasive technique that produces spectra of metabolites rather than images and can be performed on commercially available MRI instruments; the probe accessory for MRS received FDA 510(k) clearance. The technique has been applied to brain tumors, stroke, seizure disorders, neurodegenerative and psychiatric conditions, and to study other organs. Although many studies demonstrate technical feasibility and suggest potential utility (for example, meta-analyses showing moderate diagnostic performance for certain brain tumor distinctions), there is a paucity of high-quality, standardized clinical trials demonstrating that MRS measurably improves diagnostic thinking, therapeutic decision-making, or patient outcomes. Multiple systematic reviews and assessments (AHRQ/Tufts, BCBSA TEC, CMS) have concluded that evidence is insufficient or limited by methodological shortcomings, heterogeneity, small sample sizes, and lack of standardization, and therefore MRS remains investigational for many indications.
| Study / Source | Key finding |
|---|---|
| Zhang et al (2014) meta-analysis | |
| Cho/Cr pooled sensitivity 0.83 and specificity 0.83 (AUC 0.9001); Cho/NAA sensitivity 0.88 and specificity 0.86 (AUC 0.9185) for differentiating recurrent glioma vs radiation necrosis | |
| Chuang et al (2016) meta-analysis | |
| Cho/Cr and Cho/NAA ratios and rCBV higher in tumor recurrence vs radiation injury; pooled differences significant though heterogeneity observed across studies | |
| CMS (2004) decision memo / national non-coverage determination | |
| Determined insufficient evidence to deem MRS reasonable and necessary for brain tumor diagnosis (national non-coverage at that time) due to methodological shortcomings | |
| Gornet et al (2019) lumbar discs vs provocative discography | |
| MRS total accuracy 85%, sensitivity 82%, specificity 88% vs discography; non‑herniated discs accuracy up to 93%; surgical success higher when treating MRS-positive discs (97% vs 57%) | |
| Baltzer & Dietzel (2013) breast MRS meta-analysis | |
| Pooled sensitivity 73%, specificity 88%, AUC 0.88; notable publication bias and between-study heterogeneity | |
| Umbehr et al (2009) prostate MRI/MRS meta-analysis | |
| Combined MRI/MRS pooled sensitivity ~68% and specificity ~85% (subpart level); may help rule-in in selected low-risk patients but limited small studies | |
| Wang et al (2014) brain tumor meta-analysis | |
| Pooled sensitivity 80.05%, specificity 78.46%, AUC 0.78; authors noted moderate study quality and technique-dependent performance | |
| Overall evidence limitations / heterogeneity | |
| Numerous meta-analyses and systematic reviews show moderate diagnostic performance for select indications but note small samples, methodological heterogeneity, publication bias, and need for standardized, multicenter outcome studies |
Evidence synthesis: MRS shows moderate diagnostic performance for some specific indications — for example, meta-analyses report pooled sensitivities and specificities for metabolite ratios (Cho/Cr and Cho/NAA) in differentiating recurrent glioma from radiation necrosis (pooled SEN/SPE ~0.83/0.83 for Cho/Cr and ~0.88/0.86 for Cho/NAA; AUCs ~0.90–0.92), and perfusion/spectroscopy combinations increase diagnostic accuracy in some studies. However, the overall body of evidence is limited by small, heterogeneous studies, methodological variability, possible publication bias, and few prospective multicenter trials; therefore further well-designed studies are needed to define MRS' clinical role and effect on outcomes.
Definitions
Glossary:
MRS — Magnetic resonance spectroscopy: Magnetic resonance spectroscopy, also known as nuclear magnetic resonance (NMR) spectroscopy; a non‑invasive technique producing spectra of metabolites rather than images.
MRS — Magnetic Resonance Spectroscopy: Noninvasive MR technique measuring biochemical/metabolic markers in tissue (eg, NAA, choline, creatine, myo‑inositol, lactate).
Pfirrmann grade — MRI-based grading system for intervertebral disc degeneration.
NAA — N‑acetylaspartate, a neuronal marker measured by MRS.
Cho — Choline-containing compounds, marker of membrane turnover.
Cr — Creatine, often used as an internal reference in MRS.
Glx — Glutamine plus glutamate peak.
Lac — Lactate.
1H-MRS — Proton magnetic resonance spectroscopy.
Medicare Determinations
| Effective | Decision / Name |
|---|---|
| 2004 | |
| CMS national non-coverage determination for MRS (brain tumor diagnosis) (NCD) — determined insufficient evidence to deem MRS reasonable and necessary for brain tumor diagnosis | |
| 2004-01-29 | |
| Decision memo for magnetic resonance spectroscopy for brain tumors — CAG-00141N (CMS) |
Revision History
Policy effective
Last review
Next review scheduled
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