CLINICAL APPROPRIATENESS GUIDELINES ADVANCED IMAGING Appropriate Use Criteria: Imaging of the Brain ARCHIVED SEPTEMBER 28, 2019 These documents have been archived because they have outdated information. They are for historical information only and should not be consulted for clinical use. Current versions of guidelines are available on the AIM Specialty Health website at http://www.aimspecialtyhealth.com/ EFFECTIVE MARCH 9, 2019 Proprietary Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details. AIM Specialty Health disclaims any responsibility for the completeness or accuracy of the information contained herein. 8600 West Bryn Mawr Avenue Appropriate.Safe.Affordable South Tower – Suite 800 Chicago, IL 60631 © 2017 ©©©© 2019 AIM Specialty Health www.aimspecialtyhealth.com 2057-0319 Imaging of the Brain Table of Contents Description and Application of the Guidelines .......................................................................................................... 4 General Clinical Guideline ........................................................................................................................................... 5 Clinical Appropriateness Framework .................................................................................................................... 5 Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions .................................................... 5 Repeat Diagnostic Intervention .............................................................................................................................. 5 Repeat Therapeutic Intervention ............................................................................................................................ 6 History ...................................................................................................................................................................... 6 Imaging of the Brain .................................................................................................................................................... 7 General Information/Overview ................................................................................................................................ 7 Scope .................................................................................................................................................................... 7 Technology Considerations ................................................................................................................................... 7 Definitions .............................................................................................................................................................. 8 Clinical Indications ...................................................................................................................................................... 9 Congenital and Developmental Conditions ........................................................................................................... 9 Ataxia, congenital or hereditary ............................................................................................................................. 9 Developmental delay (Pediatric only) .................................................................................................................... 9 Congenital cerebral anomalies ............................................................................................................................ 10 Infection .................................................................................................................................................................. 10 Infection ............................................................................................................................................................... 10 Inflammatory Conditions....................................................................................................................................... 11 Multiple sclerosis and other white matter diseases ............................................................................................. 11 Inflammatory conditions, unspecified .................................................................................................................. 11 Trauma .................................................................................................................................................................... 11 Trauma ................................................................................................................................................................ 11 Tumor or Neoplasm ............................................................................................................................................... 12 Acoustic neuroma (Adult only) ............................................................................................................................. 12 Pituitary adenoma (Adult only) ............................................................................................................................ 13 Tumor – not otherwise specified .......................................................................................................................... 13 Miscellaneous Conditions..................................................................................................................................... 14 Bell’s palsy (peripheral facial nerve palsy)........................................................................................................... 14 Cerebrovascular accident or transient ischemic attack ....................................................................................... 14 Dementia (Adult only) .......................................................................................................................................... 15 Horner’s syndrome .............................................................................................................................................. 16 Hydrocephalus/ventricular assessment ............................................................................................................... 16 Mental status change and encephalopathy ......................................................................................................... 17 Movement disorders (Adult only) ......................................................................................................................... 17 Neurocutaneous disorders .................................................................................................................................. 18 Pseudotumor cerebri (Pediatric only) .................................................................................................................. 18 Seizure disorder .................................................................................................................................................. 18 Seizure, refractory ............................................................................................................................................... 19 Copyright © 2019. AIM Specialty Health. All Rights Reserved. 2 Imaging of the Brain Trigeminal neuralgia and persistent idiopathic facial pain (Adult only) ................................................................ 20 Perioperative/Periprocedural Imaging ................................................................................................................. 20 Lumbar puncture risk assessment ....................................................................................................................... 20 Signs and Symptoms ............................................................................................................................................ 20 Dizziness or vertigo ............................................................................................................................................. 21 Headache ............................................................................................................................................................ 21 Hearing loss ........................................................................................................................................................ 25 Papilledema ......................................................................................................................................................... 25 Syncope .............................................................................................................................................................. 26 Tinnitus (Adult only) ............................................................................................................................................. 26 Visual disturbance ............................................................................................................................................... 26 Codes ...................................................................................................................................................................... 27 References ............................................................................................................................................................. 27 History ...................................................................................................................................................................