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    v1.0.28
    OpenPayerPolicy UpdatesRadiology/Diagnostic ImagingWPS Health Insurance Head MRI Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentWPS Health InsurancePolicy PUM 250-0060-1812

    MRI (Magnetic Resonance Imaging) of Head/Brain Medical Guideline

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    This guideline governs medical-necessity and prior-authorization requirements for MRI of the head, brain, and internal auditory canal, including functional and follow-up imaging. It applies to providers requesting these services for WPS Health Insurance members, subject to the member's benefit plan, applicable law, and state mandates.

    Policy Summary
    PayerWPS Health Insurance
    PolicyMRI (Magnetic Resonance Imaging) of Head/Brain Medical Guideline
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewSep 10, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with a standard written order, medical records supporting medical necessity, and correct coding when required by the applicable benefit plan or contract.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    30numbered coverage indication categories
    6 monthsrepeat brain MRI interval requiring additional justification
    1-3 yearspermitted long-term follow-up interval for selected meningiomas
    Not medically necessary

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    unsupported uses
    Annualselected hereditary-condition screening frequency

    Covered and Non-Covered Criteria

    Neurological Symptoms

    Head MRI is medically necessary when ANY of the following neurological symptom criteria is met:

    ANY of the following

    • Unexplained, persistent headache occurring at least 3 times per month with severe intensity or documented interference with daily activities or ADLs; excludes typical migraine with a normal neurologic examination, with or without aura.
    • Chronic headache with a change in frequency, severity, or duration.
    • Cluster headache or other trigeminal-autonomic cephalgia, including paroxysmal hemicrania, hemicrania continua, or short-lasting unilateral neuralgiform headache attacks.

    • Acute headache with ANY associated feature

      • Acute, sudden-onset headache.

      • ANY of the following

        • Personal history or first-degree relative with brain aneurysm or arteriovenous malformation.
        • Extreme or thunderclap headache.
        • Prior stroke or intracranial bleed.
        • Known coagulopathy or anticoagulant use.
        • Focal neurologic findings, including mental-status, motor, sensory, speech, or visual deficits; gait disturbance; acute loss of dexterity or coordination; or evidence of elevated intracranial pressure.
        • Cancer.
        • Immunocompromised state.

    • Pediatric persistent headache with ANY associated feature

      • Persistent headache in a pediatric patient.

      • ANY of the following

        • Occipital headache.
        • Age younger than 6 years.
        • Symptoms of increased intracranial pressure, such as recurring headaches after waking.
        • Underlying disease predisposing to intracranial pathology, including immune deficiency, sickle cell disease, neurofibromatosis, history of neoplasm, coagulopathy, hypertension, or congenital heart disease; documentation must specify the condition and predisposition.
    • Clinical suspicion of cerebrospinal-fluid leak supported by patient history or physical-examination findings.
    • Unexplained focal neurologic deficit or change in an existing deficit.
    • New-onset dementia or cognitive impairment of unclear cause.

    Known or Suspected Seizure Disorders

    Coverage is provided when ANY of the following seizure-related criteria is met:

    ANY of the following

    • Initial assessment after a first unprovoked seizure, excluding pediatric simple febrile seizures, idiopathic focal or generalized epilepsy with typical features, BECTS, childhood absence epilepsy, juvenile absence epilepsy, and juvenile myoclonic epilepsy.

    • Ongoing epilepsy management

      • Additional information from MRI is required because of a change in clinical condition.

      • ANY of the following

        • Change in seizure pattern.
        • Status epilepticus.

    Known or Suspected Cranial Trauma

    Coverage is provided when ANY of the following cranial-trauma criteria is met:

    ANY of the following

    • Evaluation of head trauma when intracranial injury is suspected.
    • Monitoring of traumatic brain injury for complications or new cognitive or neurologic deficits.
    • Persistent or disabling post-concussive syndrome when MRI has not already been performed.

    Tumors, Cysts, and Cancer Surveillance

    Coverage is provided for tumors, cysts, hereditary syndromes, and cancer surveillance when ANY applicable criterion below is met:

    ANY of the following

    • Intracranial neoplasm evaluation

      • Acute, new, or fluctuating neurologic symptoms, including mental-status, motor, sensory, speech, or visual deficits; gait disturbance; acute loss of dexterity or coordination; or elevated intracranial pressure.
      • Suspected brain metastasis or intracranial cancer involvement based on neurologic symptoms or examination findings, which may include new or changing lymph nodes.
      • Further evaluation of a lesion identified on other imaging or discovered incidentally.
    • Central diabetes insipidus.

    Vascular Abnormalities

    Head MRI is medically necessary when ANY of the following vascular criteria is met:

    ANY of the following

    • Assessment of a known or suspected vascular condition, such as aneurysm, arteriovenous malformation, or ischemic event.
    • Known or suspected stroke with signs or symptoms including aphasia, ataxia, decreased consciousness, dysarthria, monocular blindness, unexplained paresthesias, visual loss, unilateral sensory or motor loss, or transient global amnesia.
    • Known or suspected transient ischemic attack.
    • Known or suspected venous thrombosis.

    • Suspected temporal arteritis

    Demyelinating Diseases

    Coverage is provided for suspected or known demyelinating disease, such as multiple sclerosis, when ANY of the following applies:

    ANY of the following

    • Initial MS evaluation based on a clinically isolated syndrome, such as optic neuritis, or recurring episodes of unexplained neurologic deficits; or a single repeat study after at least 6 months to document progression or dissemination in time.
    • Baseline imaging, postpartum imaging, imaging 3 to 6 months after a change in disease-modifying therapy, and one follow-up study at 6 to 12 months.
    • One-time 6-month repeat scan for MRI disease activity without new clinical symptoms, such as radiographically isolated syndrome.
    • New neurologic signs or symptoms concerning for disease progression.
    • Imaging before starting or changing disease-modifying therapy.

    Infection, Neurodegenerative Disease, and Movement Disorders

    Coverage is provided for suspected or known CNS infection, neurodegenerative disease, or movement disorder when ANY of the following criteria is met:

    ANY of the following

    • CNS infection

      • Suspected CNS infection, abscess, meningitis, or encephalitis based on examination, mental-status change, stiff neck, or positive laboratory findings such as elevated white blood cells or abnormal lumbar-puncture fluid.
      • Endocarditis with suspected septic emboli.
      • Suspected CNS involvement in known or suspected vasculitis or autoimmune disease with abnormal inflammatory markers or autoimmune antibodies.

    • Neurodegenerative disease

      • One-time evaluation of cognitive impairment of unknown etiology, memory loss, or mental-status change, including an unexpected change in existing symptoms or clinical course.

    Structural, Developmental, Pituitary, and Cranial-Nerve Conditions

    Coverage is provided for the following structural, developmental, pituitary, and cranial-nerve conditions when the stated criterion is met:

    ANY of the following

    • Suspected or known congenital anomaly of the brain or spine.
    • Suspected or known hydrocephalus.
    • Unexplained trigeminal neuralgia or objective palsy of cranial nerves 9, 10, 11, or 12.
    • Intracranial hemorrhage.
    • Known or suspected leukodystrophy or leukoencephalopathy.

    Specialized Head, Brain, and Internal Auditory Canal Imaging

    Coverage is provided for specialized head, brain, and internal auditory canal imaging when ANY applicable indication below is met:

    ANY of the following

    • Suspected or known acoustic neuroma.

    • Chiari malformation

      • One-time imaging for suspected Chiari malformation.
      • Re-evaluation of known Chiari malformation with new or changing signs, symptoms, or examination findings.
    • Diagnosis or follow-up of known or suspected neurosarcoidosis.
    • Preoperative or postoperative imaging for neurosurgical procedures.

    Repeat MRI Within 6 Months

    Unless addressed by another indication of coverage, repeat brain MRI within 6 months of similar imaging requires ANY of the following documented justifications:

    ANY of the following

    • The prior test was inconclusive or short-term follow-up imaging was needed.

    • ALL of the following

      • Progressive worsening of symptoms or new physical-examination findings prompted repeat imaging.
      • Patient management will be altered by the imaging results.
    • Interval surgery with suspected complication or significant new trauma to the same anatomic region.

    Screening asymptomatic patients who are at low risk for head or brain disease is not medically necessary.

    Monitoring stable patients with known head or brain disease is not medically necessary.

    Using head or brain MRI to guide invasive procedures intraoperatively is not medically necessary.

    MRI performed for research purposes, including determining eligibility for participation in clinical trials, is not medically necessary.

    MRI for essential tremor, Tourette syndrome, or isolated focal dystonia—including blepharospasm, cervical dystonia, laryngeal dystonia, oromandibular dystonia, and writer’s dystonia—is not medically necessary, except when the covered MRI-guided focused-ultrasound surgery criteria are met.

    Brain MRI for autism is not medically necessary unless there are new or worsening neurologic findings, developmental regression, or another indication of coverage is met.

    MRI for migraine with a normal neurologic examination is not medically necessary when none of the listed indications of coverage is present.

    A listed condition or diagnosis that does not meet the applicable medical-necessity criteria is not medically necessary.

    Use for a condition or diagnosis other than one listed in the indications of coverage is considered experimental, investigational, and unproven to affect health outcomes.

    Clinical Thresholds and Follow-Up Intervals

    Persistent severe headache
    FrequencyAt least 3 episodes per month
    SeveritySevere intensity
    Functional impactDocumented interference with daily activities or activities of daily living (ADLs)
    New headache age threshold
    Age thresholdAge at least 50 years
    Clinical contextNew onset of headache
    Coverage contextListed as a red flag for acute headache evaluation

    Authorization and Documentation Requirements

    Prior Authorization

    Submit Prior Authorization With Clinical Records

    Before requesting authorization, submit a standard written order prescribed by a qualified healthcare provider and include the clinical records supporting the member’s diagnosis, medical necessity, and continued need or use when applicable.

    • Submit the order and supporting clinical records with the prior-authorization request.
    • Use correct coding that meets all applicable coding guidelines.
    Documentation Required

    Prior-Authorization Submission Requirements

    Prior-authorization submissions must identify the diagnosis and provide sufficient clinical information for review of the requested head or brain MRI. Include the order, relevant history and examination findings, prior imaging or treatment, and any other information supporting the specific indication.

    • Standard written order from a qualified healthcare provider.

    Clinical Background

    Head and brain MRI is a noninvasive imaging technique that uses a strong magnetic field and radio waves to produce detailed images of the brain and surrounding tissues. It may support diagnosis, treatment planning, postoperative assessment, and monitoring of response or progression in conditions such as brain tumors, multiple sclerosis, and hydrocephalus.

    Policy Definitions

    Head and brain MRI
    TechniqueNoninvasive imaging technique
    TechnologyUses a strong magnetic field and radio waves
    PurposeCreates detailed images of the brain and surrounding tissues
    Medically necessary
    DefinitionA service necessary for prevention, diagnosis, or treatment of a medical condition or injury
    PreventionMay be necessary to prevent a medical condition or injury
    Diagnosis or treatmentMay be necessary to diagnose or treat a medical condition or injury

    Covered Indication Categories

    Neurological Symptoms

    Covered indications include:

    Neurological symptoms: Qualifying persistent or changing headache, cluster headache or other trigeminal-autonomic cephalalgia, acute headache with red flags, pediatric headache with a listed risk factor, suspected CSF leak, unexplained focal neurologic deficit, or new dementia or cognitive impairment of unclear cause.

    Seizure Disorders, Trauma, Tumors, Vascular Abnormalities, and Lesions

    Covered indications include:

    Seizure, trauma, tumor, vascular, and cyst conditions: First unprovoked seizure or qualifying epilepsy change; suspected intracranial trauma; suspected or known tumor or lesion; qualifying aneurysm, arteriovenous malformation, ischemic event, stroke, TIA, venous thrombosis, or temporal arteritis; or qualifying cyst and cancer surveillance.

    Demyelinating and CNS Infectious Diseases

    Covered indications include:

    Imaging Frequency Limits

    MRI — meningioma observation imaging frequency
    Initial scheduleAt 3, 6, and 12 months
    Five-year scheduleEvery 6 months for 5 years
    Long-term scheduleEvery 1–3 years as clinically indicated
    MRI — MEN1 screening frequency
    ConditionMultiple Endocrine Neoplasia, Type 1 (MEN1)
    ModalityBrain MRI
    FrequencyEvery 3–5 years from age 5

    Prior Authorization

    Prior Authorization

    Confirm whether prior authorization is required

    Prior authorization is required for MRI of the head, brain, internal auditory canal, and related covered MRI services when required by the applicable benefit plan or contract. Confirm the member’s plan and contract requirements before scheduling or submitting the service.

    Non-Covered Uses

    Head or brain MRI is not medically necessary for low-risk asymptomatic screening, monitoring stable known head or brain disease, or guiding invasive procedures intraoperatively. It is also not medically necessary for research or clinical-trial eligibility; essential tremor, Tourette syndrome, or isolated focal dystonia unless another covered criterion applies; autism without new or worsening neurologic findings, developmental regression, or another covered indication; or migraine with a normal neurologic examination when no other covered indication is present.

    Policy Summary
    PayerWPS Health Insurance
    PolicyMRI (Magnetic Resonance Imaging) of Head/Brain Medical Guideline
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewSep 10, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with a standard written order, medical records supporting medical necessity, and correct coding when required by the applicable benefit plan or contract.
    SourceLink
    On This Page
    Covered and Non-Covered CriteriaClinical Thresholds and Follow-Up IntervalsAuthorization and Documentation RequirementsClinical BackgroundPolicy DefinitionsCovered Indication CategoriesImaging Frequency LimitsPrior AuthorizationNon-Covered Uses
  1. Pregnancy, including the puerperium.
  2. Subacute head trauma.
  3. Severe unilateral headache radiating to or from the neck with suspected carotid or vertebral artery dissection.
  4. Progressively worsening headache.
  5. New-onset headache in a patient age 50 or older.
  6. Headache strictly related to exertion, including sexual activity, exercise, or Valsalva maneuver.
    7. Seizures refractory to medical management.
    Precocious puberty with hormonal studies suggesting a central cause.
  7. Pituitary apoplexy with sudden neurologic and hormonal symptoms.
  8. Follow-up of a known brain lesion to assess progression, treatment response, or suspected recurrence of a previously treated condition.
  9. Observation-only management of a meningioma—at 3, 6, and 12 months; every 6 months for 5 years; then every 1 to 3 years as clinically indicated.
  10. Screening for non-CNS cancers and hereditary cancer syndromes in accordance with NCCN guidelines.

  11. Screening for specified hereditary conditions

    • MEN1: brain MRI every 3 to 5 years from age 5.
    • Tuberous sclerosis: brain and abdominal MRI every 1 to 3 years until age 25.
    • Hereditary paraganglioma-pheochromocytoma syndrome: annual whole-body MRI beginning at age 8.
    • Li-Fraumeni syndrome: annual screening throughout life.
    • Von Hippel-Lindau disease: biannual screening beginning at age 10.
    • Neurofibromatosis type 1: annual screening.
    • Neurofibromatosis type 2: annual cranial and spinal MRI from ages 10 through at least 40, and thereafter as needed.

  12. Known cysts and lesions

    • Follow-up of a known Rathke cleft cyst.

    • Known arachnoid cyst

      • Patient younger than 4 years: serial imaging.
      • Patient older than 4 years with new symptoms, increased intracranial pressure, hydrocephalus, local mass effect, seizures, or visual or endocrine dysfunction.
    • Follow-up of a pineal cyst at least 5 mm with associated symptoms, or one-time follow-up of a pineal cyst at least 5 mm with atypical imaging features.
    • Midline dermoid cyst or sinus with concern for intracranial extension.
  13. Other evaluation or monitoring of cancer explicitly recommended by NCCN guidelines.
    14. Patient older than 50 with temporal headache, abrupt visual changes, jaw claudication, temporal-artery tenderness, constitutional symptoms, or elevated ESR.

  14. ANY of the following

    • Negative initial color-Doppler ultrasound or biopsy work-up.
    • Atypical features, failure to respond to treatment, or specific concern for intracranial involvement.
  15. Surveillance imaging every 1 to 2 years.
  16. Known, suspected, or high risk for progressive multifocal leukoencephalopathy, with imaging every 3 to 4 months.
  17. Suspected Parkinson disease with atypical features or unresponsiveness to levodopa.
  18. New non-Parkinson neurologic symptoms in known Parkinson disease that complicate evaluation of the current condition.
  19. Evaluation of another movement disorder to exclude a structural lesion, including suspected Huntington disease, chorea, atypical parkinsonian syndrome, hemiballismus, or atypical dystonia.

  20. MRI-guided focused-ultrasound surgery

    • Diagnosis of essential tremor.
    • Failure of, intolerance to, or contraindication to at least 2 medication treatments, such as propranolol, primidone, carbamazepine, or gabapentin.
    • Tremor interferes with daily activities.
    • Unilateral treatment is planned.
    21. Tinnitus, pulsatile or nonpulsatile.
  21. Sickle cell disease when imaging is needed to identify silent cerebral infarcts for chronic-transfusion or cognitive-screening decisions.
  22. Postoperative imaging after shunt placement or endoscopic third ventriculostomy, with follow-up at 6 to 12 months and then every 12 months when clinically stable, or when shunt malfunction or infection is suspected.

  23. Developmental delay

    • Significant delay or failure to reach milestones in at least 2 developmental domains.

    • ANY of the following

      • Gross or fine motor control.
      • Speech or language.
      • Cognition.
      • Social or personal function.
      • Activities of daily living.
  24. One-time scan of a child with cerebral palsy.

  25. Pituitary disorder

    • Hypopituitarism.
    • Growth hormone deficiency.
    • Hypogonadotropic hypogonadism.
    • Central hyperthyroidism.
    • Suspected Cushing syndrome with high ACTH and cortisol suppression on low- or high-dose dexamethasone testing.
    • Acromegaly or gigantism with high GH or IGF-1.
    • Elevated prolactin.
    • Pituitary incidentaloma surveillance: macroincidentaloma at 6 months, then annually for 3 years if stable and less often thereafter; microincidentaloma at 1 year, then every 1 to 2 years for 3 years if stable and less often thereafter.

  26. Cranial-nerve or spinal-accessory-nerve disorder

    • Known or suspected optic neuritis.

    • Eye abnormality

      • Papilledema.
      • Nystagmus.
      • Optic atrophy.
      • Ocular nerve palsy.
      • New anisocoria.
      • New visual-field defect.
      • Binocular diplopia.
      • Childhood strabismus with developmental delay or abnormal funduscopic examination.
    • New Horner syndrome or initial evaluation of congenital Horner syndrome.
    • Atypical occipital neuralgia.

    • Bell palsy

      • Bell palsy.

      • ANY of the following

        • Atypical presentation.
        • Slow resolution exceeding 3 weeks.
        • No improvement at 4 months.
        • Facial twitch or spasm at onset.
    • Cranial-nerve palsy.
    • Anosmia or hyposmia not explained by COVID-19 or another known etiology.
  27. Further evaluation based on CT, x-ray, or cranial-ultrasound findings.
  28. BRUE/ALTE in an infant when history or examination is concerning for a neurologic cause.

  29. Functional brain MRI for presurgical planning

    • Identification of eloquent cortex for brain tumor surgery, except temporal tumors.
    • Epilepsy, except temporal neocortical epilepsy.
    • Vascular malformation.

  30. Vertigo or dizziness

    • Additional signs or symptoms suggestive of a CNS lesion.
    • Tullio phenomenon.
    • Symptoms with an abnormal audiogram or vestibular-function test suggesting an intracranial or vestibulocochlear mass lesion.

  31. Internal auditory canal MRI

    • Pulsatile or unilateral tinnitus.
    • Asymmetric sensorineural hearing loss or suspected acoustic neuroma or schwannoma.
    • Preoperative cochlear-implant planning.
    • CSF otorrhea: intermittent leaks; for active leaks only when CT is contraindicated, unavailable, or indeterminate.
    • Congenital or childhood sensorineural hearing loss.
    • Cholesteatoma only when CT is indeterminate, contraindicated, or unavailable.
    • Unexplained sensorineural hearing loss.
    • Sensorineural hearing loss associated with vertigo or dizziness.
    • Mixed conductive and sensorineural hearing loss.
    • Conductive hearing loss requiring surgical planning.
    32. Pediatric headache age threshold
    Age thresholdAge less than 6 years
    Clinical contextPersistent headache in a pediatric patient
    Coverage contextListed as a pediatric headache risk factor
    MEN1 screening
    ConditionMultiple Endocrine Neoplasia, Type 1 (MEN1)
    ImagingBrain MRI
    IntervalEvery 3–5 years from age 5 years
    Tuberous sclerosis screening
    ConditionTuberous sclerosis
    ImagingMRI of the brain and abdomen
    IntervalEvery 1–3 years until age 25
    VHL screening
    ConditionVon Hippel-Lindau (VHL) disease
    IntervalEvery 2 years
    Starting ageBeginning at age 10
    Meningioma observation follow-up
    Initial follow-upAt 3, 6, and 12 months
    Intermediate follow-upEvery 6 months for 5 years
    Long-term follow-upEvery 1–3 years as clinically indicated
    PML surveillance
    ConditionKnown, suspected, or high risk for progressive multifocal leukoencephalopathy (PML)
    ImagingBrain MRI surveillance
    IntervalEvery 3–4 months
    Post-shunt or ETV follow-up
    ProcedureShunt placement or endoscopic third ventriculostomy (ETV)
    Post-procedure imaging6–12 months after the procedure
    Stable follow-upEvery 12 months when clinical findings are stable
    Pituitary macroincidentaloma follow-up
    Initial follow-up6 months after the initial scan
    Stable follow-upAnnually for the next 3 years if stable in size
    Later follow-upLess often thereafter
    Pituitary microincidentaloma follow-up
    Initial follow-up1 year after the initial scan
    Stable follow-upEvery 1–2 years for the next 3 years if stable in size
    Later follow-upLess often thereafter
    Repeat MRI interval
    TimingWithin 6 months of similar imaging
    RequirementAdditional criteria must be documented
    Applies whenNo other indication of coverage specifically addresses the repeat study
  32. Member diagnosis and the specific clinical indication for MRI.
  33. Relevant medical records documenting symptoms, findings, medical necessity, and continued need or use when applicable.
  34. Correct service coding that complies with coding guidelines.
    35. Documentation Required

    Document the Reason for an Early Repeat MRI

    For a repeat brain MRI requested within 6 months of similar imaging, document at least one qualifying reason for the short-term repeat study.

    • The prior test was inconclusive or short-term follow-up imaging was needed.
    • Symptoms progressively worsened or new physical-examination findings prompted repeat imaging, and management will be altered by the results.
    • Interval surgery with suspected complication or significant new trauma to the same anatomic region.
    Documentation Required

    Support the Clinical Indication

    Support the MRI request with documentation of the patient’s symptoms, examination findings, diagnosis or suspected condition, and the specific indication meeting the guideline. Include relevant prior imaging, testing, treatment history, and clinical changes when they support medical necessity.

    • Neurologic symptoms or focal deficits, cognitive or mental-status changes, headache features, seizure history, trauma, suspected tumor, vascular or infectious disease, neurodegenerative disease, hearing loss, vertigo or dizziness, or another listed indication.
    • Relevant abnormal examination, audiogram, vestibular testing, laboratory, CT, x-ray, ultrasound, or prior MRI findings.
    • For follow-up or repeat imaging, document progression, new symptoms or findings, treatment changes, prior imaging results, and how the MRI will affect management.
    • For pediatric or condition-specific requests, specify the qualifying age, underlying disease, risk factor, or other criterion required by the indication.
    Denial Risk

    Unlisted or Unmet Indication

    Requests for a condition or diagnosis not listed under the guideline’s Indications of Coverage are considered experimental, investigational, and unproven to affect health outcomes. Such services are not medically necessary under the guideline and will not be covered, subject to the applicable benefit plan and law.

    • Confirm that the diagnosis and requested use match a listed indication before submitting authorization.
    • If a listed indication’s criteria are not met, the service is considered not medically necessary.
    Denial Risk

    Avoid Insufficient Justification for Early Repeat Imaging

    An early repeat MRI may be denied when the required short-term follow-up documentation is absent. Requests within 6 months of similar imaging must explain why repeat imaging is needed and, when applicable, how the results will change management.

    • Do not rely only on a diagnosis or a routine follow-up statement.
    • Document an inconclusive prior study, required short-term follow-up, progressive worsening or new examination findings with an anticipated management change, interval surgery with suspected complication, or significant new trauma.
    • If none of these circumstances is documented, the repeat study does not satisfy the early-repeat criterion.
    Denial Risk

    Explicit Non-Covered Uses

    Head and brain MRI is not medically necessary for uses expressly excluded by the guideline, unless another listed Indication of Coverage applies and its criteria are met.

    • Screening asymptomatic patients at low risk for head or brain disease.
    • Monitoring patients with stable known head or brain disease.
    • Guiding invasive procedures intraoperatively.
    • Research purposes, including determining eligibility for clinical trials.
    • Essential tremor, Tourette syndrome, or isolated focal dystonia.
    • Autism without new or worsening neurologic findings, developmental regression, or another listed indication.
    • Migraine with a normal neurologic examination and none of the listed qualifying conditions.
    Note

    Positional Vertigo Does Not Require Advanced Imaging

    Vertigo or dizziness that is clearly related to positional change does not require advanced imaging under the listed criterion. Submit an MRI request for vertigo or dizziness only when a qualifying scenario is documented.

    • Additional signs or symptoms suggestive of a central nervous system lesion.
    • Tullio phenomenon (noise-induced dizziness).
    • Abnormal audiogram or vestibular-function testing suggestive of an intracranial or vestibulocochlear mass lesion.
    BRUE/ALTE
    MeaningBrief Resolved Unexplained Event (BRUE) or ALTE in an infant
    Coverage requirementHistory or examination findings must be concerning for a neurologic cause
    Imaging contextHead or brain MRI is covered when the neurologic-cause requirement is met
    Demyelinating and CNS infectious diseases: Suspected or known multiple sclerosis or other demyelinating disease, CNS infection, abscess, meningitis, encephalitis, septic emboli, or CNS involvement in vasculitis or autoimmune disease when the guideline criteria are met.

    Structural, Developmental, Pituitary, Cranial-Nerve, and Sensory Conditions

    Covered indications include:

    Structural, developmental, pituitary, cranial-nerve, and sensory conditions: Qualifying neurodegenerative or movement disorder, congenital anomaly, hydrocephalus, developmental delay, pituitary disorder or incidentaloma, cranial-nerve or ocular abnormality, tinnitus, hearing loss, cholesteatoma, intracranial hemorrhage, leukodystrophy or leukoencephalopathy, sickle-cell disease evaluation, or postoperative shunt or ETV follow-up.

    Specialized Head, Brain, and Internal Auditory Canal MRI

    Covered indications include:

    Specialized imaging: Acoustic neuroma, Chiari malformation, neurosarcoidosis, internal auditory canal indications, preoperative or postoperative neurosurgical imaging, functional presurgical mapping, concerning BRUE/ALTE, further evaluation after CT, x-ray, or cranial ultrasound, or qualifying vertigo or dizziness.

    Clearly positional vertigo or dizziness does not require advanced imaging.

    MRI — tuberous sclerosis screening frequency
    ConditionTuberous sclerosis
    ImagingMRI of the brain and abdomen
    FrequencyEvery 1–3 years until age 25
    MRI — surveillance frequency
    Surveillance contextBrain MRI surveillance for demyelinating disease
    FrequencyEvery 1–2 years
    Additional high-risk schedulePML surveillance is every 3–4 months
    MRI — post-procedure follow-up frequency
    ProcedureShunt placement or endoscopic third ventriculostomy (ETV)
    First follow-up6–12 months after the procedure
    Stable follow-upEvery 12 months when clinically stable
    MRI — pituitary macroincidentaloma frequency schedule
    First follow-up6 months after the initial scan
    Stable intervalAnnually for the next 3 years if stable in size
    Later intervalLess often thereafter
    MRI — pituitary microincidentaloma frequency schedule
    First follow-up1 year after the initial scan
    Stable intervalEvery 1–2 years for the next 3 years if stable in size
    Later intervalLess often thereafter