CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria — Magnetic Resonance Spectroscopy (MRS)

Criteria governing medical necessity and coverage determinations for Magnetic Resonance Spectroscopy (MRS) for Kaiser Foundation Health Plan of Washington members, including Medicare and non‑Medicare populations.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Magnetic Resonance Spectroscopy (MRS)

Policy CodePolicy N/A

Change TypeAdopted MCG/hybrid criteriaprior administrative revisions

Effective DateN/A

Next Review DateN/A

Key ActionVerify pre-authorization requirements and, if requesting review, submit the last 6 months of clinical notes from the requesting provider and/or specialist.

SourceLink

POLICY UPDATE CHANGES

MPC approved to adopt MCG/hybrid criteria for Magnetic Resonance Spectroscopy.

MPC approved to remove MCG guideline A-0482 and to retain policy of non-coverage; added requirement that Clinical Review physician consult KP Neuroradiology on requests.

1CPT code considered not medically necessary

190,000+Annual US diagnoses of primary/metastatic cerebral tumors

87%MRS lateralization agreement with EEG in one study

81–90% / 86–100%Reported sensitivity / specificity range (small studies)

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Magnetic Resonance Spectroscopy (MRS)

Policy CodePolicy N/A

Change TypeAdopted MCG/hybrid criteriaprior administrative revisions

Effective DateN/A

Next Review DateN/A

Key ActionVerify pre-authorization requirements and, if requesting review, submit the last 6 months of clinical notes from the requesting provider and/or specialist.

SourceLink

On This Page

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Not Medically Necessary / Insufficient Evidence

Policy-level coverage stance and identified clinical indications evaluated:

Diagnoses evaluated but not meeting KP assessment criteria: Use of MRS to diagnose ADHD, autism, or epilepsy does not meet Kaiser Permanente Medical Technology Assessment criteria.

Document states no published studies establishing diagnostic accuracy for these conditions.

Cerebral tumors / tumor vs non-tumor: Use of MRS in diagnosing cerebral tumors and differentiating tumors from non-tumors does not meet Kaiser Permanente Medical Technology Assessment criteria.

Small studies reported but evidence insufficient to conclude diagnostic or therapeutic impact.

The policy evaluates the clinical role of Magnetic Resonance Spectroscopy (MRS) for several neurological indications. Evidence reviews considered MRS as an adjunct to conventional MRI for: (1) diagnosing developmental/neurobehavioral conditions such as autism and ADHD; (2) evaluating seizure disorders such as epilepsy; and (3) characterization of intracranial mass lesions, including use in diagnosing cerebral tumors and helping to differentiate tumor versus non‑tumor lesions. The policy notes that MRS has been studied for lateralization in temporal lobe epilepsy and for metabolic characterization of suspected malignant brain tumors, but that the available studies are limited and have not demonstrated sufficient diagnostic accuracy or impact on clinical management to meet Kaiser Permanente Medical Technology Assessment criteria.

Per this policy, Magnetic Resonance Spectroscopy (CPT 76390) is considered Not Medically Necessary for the reviewed indications, including use to diagnose ADHD, autism, epilepsy, and for characterization or differentiation of cerebral tumors from non‑tumor lesions.

Provider Actions and Authorization

Documentation Required

Documentation Required for Review

Required documentation must be submitted for clinical review. Include the most recent clinical information to support medical necessity determinations.

Last 6 months of clinical notes from the requesting provider and/or specialist
Any relevant imaging reports and prior test results referenced in the clinical notes

Note

Guideline Source for Determinations

Guideline source for determinations differs by member type. For Non‑Medicare members Kaiser Permanente uses the MCG Care Guideline 'Magnetic Resonance Spectroscopy' (KP-0482). For Medicare members, in the absence of CMS/MAC coverage guidance, Kaiser Permanente applies its own Clinical Review Criteria titled 'Magnetic Resonance Spectroscopy'.

Non‑Medicare: MCG Care Guideline — Magnetic Resonance Spectroscopy (KP-0482). Access via MCG Guideline Index on the provider portal; criteria are proprietary but may be shared on an individual member basis upon request.
Medicare: Kaiser Permanente Clinical Review Criteria — Magnetic Resonance Spectroscopy (used when CMS/NCD/LCD guidance is absent)

Background

Magnetic Resonance Spectroscopy (MRS) is a non‑invasive MR‑based technique that generates spectra representing relative concentrations of chemical metabolites in tissue rather than anatomical images. Commonly measured metabolites in proton (1H) MRS include lipids, lactate, N‑acetylaspartate (NAA), glutamate/glutamine (Glx), creatine (Cr), choline (Cho) and myo‑inositol (mI). MRS has been proposed as a tool to assist with tumor characterization, guide biopsy targets, monitor therapy response, and provide metabolic information to complement MRI; however, the policy’s evidence review found the literature limited and insufficient to support routine clinical use for the indications evaluated.

Definitions and Measured Metabolites

Proton (1H) MRS metabolites

Commonly measured metabolitesLipids; Lactate; N-acetylaspartate (NAA); Glutamate/glutamine (Glx); Creatine (Cr); Choline (Cho); Myoinositol (mI)

Number of brain metabolites defined by proton (1H) MRSApproximately 15 brain metabolites

Tumor-associated chemical profileIncreased Cho with reduced Cr and NAA may be characteristic of brain tumors

Magnetic Resonance Spectroscopy (MRS)

DefinitionMagnetic Resonance Spectroscopy (MRS) is a non-invasive MR-based technique that generates a spectral waveform with peaks corresponding to the relative concentrations of chemicals in tissue; the proton (1H) is the most commonly studied nucleus

OutputA waveform/spectrum with peaks at different positions on a horizontal axis identifying specific chemicals and their relative concentrations

Clinical useUsed for metabolic profiling of tissue (alone or with MRI) to assist in diagnosis, tumor characterization, biopsy guidance, and therapy monitoring

OpenPayer

Clinical Review Criteria — Magnetic Resonance Spectroscopy (MRS)

Coverage Criteria for Magnetic Resonance Spectroscopy (MRS)

Coding and Billing

Provider Actions and Authorization

Background

Definitions and Measured Metabolites