Functional Magnetic Resonance Imaging

Number: 0739

Policy

Aetna considers functional magnetic resonance imaging (fMRI) medically necessary to identify the eloquent cortex in pre-surgical evaluation of persons with brain tumors (except temporal tumors), epilepsy (except temporal neocortical epilepsy), or vascular malformations.

Aetna considers fMRI experimental and investigational to identify the eloquent cortex in pre-surgical evaluation of persons with temporal neocortical epilepsy or temporal tumors.

Aetna considers fMRI experimental and investigational for the diagnosis, monitoring, prognosis, or surgical management of all other indications, including any of the following conditions/diseases (not an all-inclusive list) because its effectiveness for these indications has not been established:

• Alzheimer's disease
• Anxiety disorder
• Anoxic-ischemic brain injury
• Attention-deficit hyperactivity disorder
• Bipolar disorder
• Childhood mal-treatment
• Chronic pain (including fibromyalgia)
• Disorders of consciousness (e.g., locked-in syndrome, minimally conscious state (subacute/chronic; traumatic/non-traumatic), and coma/vegatative state)
• Multiple sclerosis
• Obsessive-compulsive disorder
• Panic disorder
• Parkinson's disease
• Psychosis
• Psychotic depression
• Schizophrenia
• Stroke/stroke rehabilitation
• Trauma (e.g., head injury).

See also CPB 0279 - Magnetic Source Imaging/Magnetoencephalography.

Background

Functional magnetic resonance imaging (fMRI) is a type of functional brain imaging technology.  It localizes regions of activity in the brain by measuring blood flow and/or metabolism following task activation, and is generally used to identify the eloquent cortex in the brain. Eloquent cortex refers to specific cortical areas in the brain that directly controls function, such as language (e.g., Broca's area, Wernicke's area) and sensorimotor function (e.g., sensorimotor cortex).  Injury, dissection or removal of that area can result in major focal neurological deficits (Byrne, 2016). Functional MRI has been used to map these areas when planning a tumor resection. Furthermore, fMRI has been employed for the diagnosis, monitoring, prognosis, or surgical management of many diseases/conditions (e.g., Alzheimer's disease, brain tumors, epilepsy, multiple sclerosis (MS), Parkinson's disease, stroke, trauma, vascular malformations, and vegetative state/coma).

The bulk of published evidence concerning the clinical applications of fMRI centers on its use in pre-surgical planning.  In particular, studies involving language fMRI mainly address its use in pre-surgical planning for epilepsy, arterio-venous malformations (AVMs), and brain tumors (Bookheimer, 2007).  It has been suggested that fMRI of the brain reduces the need for invasive testing of seizure disorder patients being considered for surgical treatment.  Woermann et al (2003) compared the determination of language dominance using fMRI with results of the Wada test in 100 patients with different localization-related epilepsies.  These investigators found 91 % concordance between both tests.  The overall rate of false categorization by fMRI was 9 %, ranging from 3 % in left-sided temporal lobe epilepsy (TLE) to 25 % in left-sided extra-temporal epilepsy.  The authors noted that language fMRI might reduce the necessity of the Wada test for language lateralization, especially in TLE.

Sabsevitz and colleagues (2003) examined whether pre-operative fMRI predicts language deficits in patients with epilepsy undergoing left anterior temporal lobectomy (L-ATL).  A total of 24 patients with L-ATL underwent pre-operative language mapping with fMRI, pre-operative intra-carotid sodium amobarbital (Amytal)/Wada testing for language dominance, as well as pre- and post-operative neuropsychological testing.  Functional MRI laterality indexes (LIs), reflecting the inter-hemispheric difference between activated volumes in left and right homologous regions of interest, were calculated for each patient.  Relationships between the fMRI LI, Wada language dominance, and naming outcome were examined.  Both the fMRI LI (p < 0.001) and the Wada test (p < 0.05) were predictive of naming outcome.  Functional MRI showed 100 % sensitivity and 73 % specificity in predicting significant naming decline.  Both fMRI and the Wada test were more predictive than age at seizure onset or pre-operative naming performance.  The authors concluded that pre-operative fMRI predicted naming decline in patients undergoing L-ATL surgery.

Medina et al (2005) prospectively evaluated effect of fMRI on diagnostic work-up and treatment planning in patients with seizure disorders who are candidates for surgical treatment.  A total of 60 consecutively enrolled patients (27 females and 33 males; mean age of 15.8 +/- 8.7 years; range of  6.8 to 44.2 years) were examined.  Forty-five (75 %) patients were right-handed, 9 (15 %) were left-handed, and 6 (10 %) had indeterminate hand dominance.  Prospective questionnaires were used to evaluate diagnostic work-up, counseling, and treatment plans of the seizure team before and after fMRI.  Confidence level scales were used to determine effect of fMRI on diagnostic and therapeutic thinking.  Paired-t test and 95 % confidence interval analyses were performed.  In 53 patients, language mapping was performed; in 33, motor mapping; and in 7, visual mapping.  The study revealed change in anatomical location or lateralization of language-receptive area -- (Wernicke's area) (28 % of patients) as well as language-expressive area (Broca's area) (21 % of patients).  Statistically significant increases were found in confidence levels after fMRI in regard to motor and visual cortical function evaluation.  In 35 (58 %) of 60 patients, the seizure team thought that fMRI results altered patient and family counseling.  In 38 (63 %) of 60 patients, fMRI results helped to avoid further studies, including the Wada test.  In 31 (52 %) and 25 (42 %) of 60 patients, intra-operative mapping and surgical plans, respectively, were altered because of fMRI results.  In 5 (8 %) patients, two-stage surgery with extra-operative direct electrocortical stimulation mapping (ESM) was averted, and resection was accomplished in one-stage.  In 4 (7 %) patients, extent of surgical resection was altered because eloquent areas were identified close to seizure focus.  The authors concluded that fMRI results influenced diagnostic and therapeutic decision making of the seizure team; results indicated a change in language dominance, an increase in confidence level in identification of critical brain function areas, alterations in patient and family counseling as well as intra-operative mapping and surgical approach.

Functional MRI has been used in pre-surgical planning for patients with brain tumors as well as vascular malformations.  Pouratian and colleagues (2002) evaluated the utility of pre-operative fMRI to predict if a given cortical area would be deemed essential for language processing by ESM.  These investigators studied patients with vascular malformations, specifically AVMs and cavernous angiomas, in whom blood-flow patterns are abnormal and in whom a perfusion-dependent mapping signal may be questionable.  A total of 10 patients were studied (7 with AVMs and 3 with cavernous angiomas).  These researchers used a battery of linguistic tasks, including visual object naming, word generation, auditory responsive naming, visual responsive naming, and sentence comprehension, to identify brain regions that were consistently activated across expression and comprehension linguistic tasks.  In a comparison of ESM and fMRI activations, the researchers varied the matching criteria (overlapping activations, adjacent activations, and deep activations) and the radii of influence of ESM (2.5, 5, and 10 mm) to determine the effects of these factors on the sensitivity and specificity of fMRI.  The sensitivity and specificity of fMRI were dependent on the task, lobe, and matching criterion.  For the population studied, the sensitivity and specificity of fMRI activations during expressive linguistic tasks were found to be up to 100 % and 66.7 %, respectively, in the frontal lobe, and during comprehension linguistic tasks up to 96.2 % and 69.8 %, respectively, in the temporal and parietal lobes.  The sensitivity and specificity of each disease population (AVMs and cavernous angiomas) and of individuals were consistent with those values reported for the entire population studied.  The authors concluded that pre-operative fMRI is a highly sensitive pre-operative planning tool for identifying cortical areas that are essential for language; and that this imaging modality may play a future role in pre-surgical planning for patients with vascular malformations.

Anderson et al (2006) examined the utility of fMRI as a determinant of lateralization of expressive language in children with cerebral lesions.  Functional MRI language lateralization was attempted in 35 children (29 with epilepsy) aged 8 to 18 years with frontal or temporal lobe lesions (28 left hemisphere, 5 right hemisphere, and 2 bilateral).  Axial and coronal fMRI scans through the frontal and temporal lobes were acquired at 1.5 Tesla (T) by using a block-design, covert word-generation paradigm.  Activation maps were lateralized by blinded visual inspection and quantitative asymmetry indices (hemispheric and inferior frontal regions of interest, at p < 0.001 uncorrected and p < 0.05 Bonferroni corrected).  A total of 30 children showed significant activation in the inferior frontal gyrus.  Lateralization by visual inspection was left in 21, right in 6, and bilateral in 3, and concordant with hemispheric and inferior frontal quantitative lateralization in 93 % of cases.  Developmental tumors and dysplasias involving the inferior left frontal lobe had activation overlying or abutting the lesion in 5 of 6 cases.  Functional MRI language lateralization was corroborated in 6 children by frontal cortex stimulation or intra-carotid Amytal testing (IAT) and indirectly supported by aphasiology in a further 6 cases.  In 2 children, fMRI language lateralization was bilateral, and corroborative methods of language lateralization were left.  Neither lesion lateralization, patient handedness, nor developmental versus acquired nature of the lesion was associated with language lateralization.  Involvement of the left inferior or middle frontal gyri increased the likelihood of atypical language lateralization.  The authors concluded that this study suggests that fMRI lateralizes language in children with cerebral lesions.

Stancanello et al (2007) attempted to validate a method to exploit functional information for the identification of functional organs at risk (fOARs) in CyberKnife radiosurgery treatment planning.  Five patients affected by AVMs and scheduled to undergo radiosurgery were scanned prior to treatment using computed tomography (CT), three-dimensional rotational angiography (3D-RA), T2 weighted and blood oxygenation level dependent echo planar imaging MRI.  Tasks were chosen on the basis of lesion location by considering those areas which could be potentially close to treatment targets.  Functional data were superimposed on 3D-RA and CT used for treatment planning.  The procedure for the localization of fMRI areas was validated by direct ESM on 38 AVM and tumor patients undergoing conventional surgery.  Treatment plans studied with and without considering fOARs were significantly different, in particular with respect to both maximum dose and dose volume histograms; consideration of the fOARs allowed quality indices of treatment plans to remain almost constant or to improve in 4 out of 5 cases compared to plans with no consideration of fOARs.  The authors concluded that the presented method provides an accurate tool for the integration of functional information into AVM radiosurgery, which might help to minimize undesirable side effects and to make radiosurgery less invasive.

There is evidence for the use of fMRI in pre-surgical planning for epilepsy and monitoring of language function during tumor resection.

Roux et al (2003) analyzed the usefulness of pre-operative language fMRI by correlating fMRI data with intra-operative ESM results for patients with brain tumors.  Naming and verb generation tasks were used, separately or in combination, for 14 right-handed patients with tumors in the left hemisphere.  Acquired fMRI data were analyzed with statistical parametric mapping software, with two standard analysis thresholds (p < 0.005 and then p < 0.05). The fMRI data were then registered in a frameless stereotactic neuro-navigational device and correlated with direct brain mapping results.  These researchers used a statistical model with the fMRI information as a predictor, spatially correlating each intra-operatively mapped cortical site with fMRI data integrated in the neuro-navigational system (site-by-site correlation).  Eight patients were also studied with language fMRI post-operatively, with the same acquisition protocol.  These investigators observed high variability in signal extents and locations among patients with both tasks.  The activated areas were located mainly in the left hemisphere in the middle and inferior frontal gyri (F2 and F3), the superior and middle temporal gyri (T1 and T2), and the supra-marginal and angular gyri.  A total of 426 cortical sites were tested for each task among the 14 patients.  In frontal and temporo-parietal areas, poor sensitivity of the fMRI technique was observed for the naming and verb generation tasks (22 % and 36 %, respectively) with p < 0.005 as the analysis threshold.  Although not perfect, the specificity of the fMRI technique was good in all conditions (97 % for the naming task and 98 % for the verb generation task).  Better correlation (sensitivity, 59 %; specificity, 97 %) was achieved by combining the two fMRI tasks.  Variation of the analysis threshold to p < 0.05 increased the sensitivity to 66 % while decreasing the specificity to 91 %.  Post-operative fMRI data (for the cortical brain areas studied intra-operatively) were in accordance with brain mapping results for 6 of 8 patients.  Complete agreement between pre- and post-operative fMRI studies and direct brain mapping results was observed for only 3 of 8 patients.  The authors concluded that with the paradigms and analysis thresholds used in this study, language fMRI data obtained with naming or verb generation tasks, before and after surgery, were imperfectly correlated with intra-operative brain mapping results.  A better correlation could be obtained by combining the fMRI tasks.  The overall results of this study showed that language fMRI could not be used to make critical surgical decisions in the absence of direct brain mapping.  Other acquisition protocols are needed for evaluation of the potential role of language fMRI in the accurate detection of essential cortical language areas.

Benke and associates (2006) noted that recent studies have claimed that language fMRI can identify language lateralization in patients with TLE and that fMRI-based findings are highly concordant with the conventional assessment procedure of speech dominance, the IAT.  These researchers attempted to establish the power of language fMRI to detect language lateralization during pre-surgical assessment and compared the findings of a semantic decision paradigm with the results of a standard IAT in 68 patients with chronic intractable right and left TLE (rTLE, n = 28; lTLE, n = 40) who consecutively underwent a pre-surgical evaluation program.  The patient group also included 14 (20.6 %) subjects with atypical (bilateral or right hemisphere) speech.  Four raters used a visual analysis procedure to determine the laterality of speech-related activation individually for each patient.  Overall congruence between fMRI-based laterality and the laterality quotient of the IAT was 89.3 % in rTLE and 72.5 % in lTLE patients.  Concordance was best in rTLE patients with left speech.  In lTLE patients, language fMRI identified atypical, right hemisphere speech dominance in every case, but missed left hemisphere speech dominance in 17.2 %.  Frontal activations had higher concordance with the IAT than did activations in temporo-parietal or combined regions of interest.  Because of methodological problems, recognition of bilateral speech was difficult.  The authors concluded that these data provide evidence that language fMRI as used in the present study has limited correlation with the IAT, especially in patients with lTLE and with mixed speech dominance.  They noted that further refinements regarding the paradigms and analysis procedures will be needed to improve the contribution of language fMRI for pre-surgical assessment.

Petrella and colleagues (2006) prospectively evaluated the effect of pre-operative fMRI localization of language and motor areas on therapeutic decision making in patients with potentially resectable brain tumors.  A total of 39 consecutive patients (19 men, 20 women; mean age of 42.2 years) referred for fMRI for possible tumor resection were evaluated.  A pre-operative diagnosis of brain tumor was made in all patients.  Sentence completion and bilateral hand squeeze tasks were used to map language and sensorimotor areas.  Neurosurgeons completed questionnaires regarding the proposed treatment plan before and after fMRI and after surgery.  They also gave confidence ratings for fMRI results and estimated the effect on surgical time, extent of resection, and surgical approach.  The effect of fMRI on changes in treatment plan was assessed with the Wilcoxon signed rank test.  Differences in confidence ratings between altered and un-altered treatment plans were assessed with the Mann-Whitney U test.  The estimated influence of fMRI on surgical time, extent of resection, and surgical approach was denoted with summary statistics.  Treatment plans before and after fMRI differed in 19 patients (p < 0.05), with a more aggressive approach recommended after imaging in 18 patients.  There were no significant differences in confidence ratings for fMRI between altered and un-altered plans.  Functional MRI resulted in reduced surgical time (estimated reduction, 15 to 60 minutes) in 22 patients who underwent surgery, a more aggressive resection in 6, and a smaller craniotomy in 2.  The authors concluded that fMRI enables the selection of a more aggressive therapeutic approach than might otherwise be considered because of functional risk.  In certain patients, surgical time may be shortened, the extent of resection increased, and craniotomy size decreased. 

Di et al (2007) assessed the differences in brain activation in response to presentation of the patient's own name spoken by a familiar voice (SON-FV) in patients with vegetative state (VS) and minimally conscious state (MCS).  By using fMRI, these investigators prospectively studied residual cerebral activation to SON-FV in 7 patients with VS and 4 patients with MCS.  Behavioral evaluation was performed by means of standardized testing up to 3 months post-fMRI.  Two patients with VS failed to show any significant cerebral activation, while 3 patients with VS showed SON-FV induced activation within the primary auditory cortex.  Finally, 2 patients with VS and all 4 patients with MCS not only showed activation in primary auditory cortex but also in hierarchically higher order associative temporal areas.  The 2 patients with VS showing the most widespread activation subsequently showed clinical improvement to MCS observed 3 months after their fMRI scan.  The authors concluded that cerebral responses to patient's own name spoken by a familiar voice as measured by fMRI might be a useful tool to pre-clinically distinguish MCS-like cognitive processing in some patients behaviorally classified as vegetative. 

The American College of Radiology (ACR)'s guideline on neurological imaging for patients with epilepsy (Karis et al, 2006) noted that the data provided by MRI are essential in the pre-surgical evaluation of patients with medically refractory epilepsy, but noted that structurally detectable abnormalities are absent in many patients.  In these patients, functional studies provide useful information on localization of the seizure focus.  In this regard, functional imaging techniques, including positron emission tomography, single-photon emission computed tomography, magnetic source imaging, and fMRI, have contributed to the pre-surgical evaluation of patients with epilepsy.  The ACR guideline provided appropriateness ratings (1 = least appropriate; 9 = most appropriate) on fMRI for the following indications:

• Chronic epilepsy, poor therapeutic response. Surgery candidate (rating = 5; may be helpful in pre-surgical planning).
• New onset of seizure. Ethyl alcohol, and/or drug-related (rating = 2).
• New onset seizure. Aged 18 to 40 years (rating = 2).
• New onset seizure. Aged greater than 40 years (rating = 2).
• New onset seizure. Focal neurological deficit (rating = 2).

Additionally, the ACR's guideline on neurological imaging for patients with head trauma (Davis et al, 2006) provided an appropriateness rating of 2 for patients with sub-acute or chronic closed head injury with cognitive and/or neurological deficit(s).

The Ontario Ministry of Health and Long-Term Care's review on functioning brain imaging (2006) stated that there may be a role for fMRI in the identification of surgical candidates for tumor resection.  The review also stated that there may be some clinical utility for fMRI in pre-surgical functional mapping.  

The assessment by the Ontario Ministry of Health and Long-Term Care (2006) stated that there is limited clinical utility of functional brain imaging in the management of patients with MS at this time.  This is in agreement with the European Federation of Neurological Societies' guideline on the use of neuro-imaging in the management of MS (Filippi et al, 2006), which stated that the use of non-conventional MRI techniques (e.g., fMRI, diffusion tensor MRI, magnetization transfer MRI, and MR spectroscopy) is not recommended.

Rocca and colleagues (2008) used fMRI to examine the properties of the mirror neuron system (MNS) in patients with MS.  Using a 3 tesla scanner, these researchers acquired fMRI in 16 right-handed patients with relapsing-remitting MS and 14 controls.  Two motor tasks were studied.  The first consisted of repetitive flexion-extension of the last 4 fingers of the right hand (simple task) alternated to epochs of rest; the second (MNS task) consisted of observation of a movie showing the hand of another subject while performing the same task.  During the simple task, compared to controls, patients with MS had more significant activations of the contralateral primary sensori-motor cortex and supplementary motor area.  During the MNS task, both groups showed the activation of several visual areas, the infra-parietal sulcus, and the inferior frontal gyrus (IFG), bilaterally.  The IFG and the visual areas were significantly more active in patients than controls.  The between-group interaction analysis showed that in patients with MS, part of the regions of the MNS were more active also during the simple task.  The authors concluded that the findings of this study suggested increased activation of the MNS in patients with MS with a normal level of function and widespread damage of the central nervous system.  The potentialities of this system in facilitating clinical recovery in patients with MS and other neurological conditions should be investigated.

In an editorial that accompanied the afore-mentioned article, Phillips (2008) stated that fMRI has tremendous potential for assessing and better understanding MS.  He noted that it is important to remember that fMRI is an indirect measurement of neuronal activity.  Also, it has been reported that there is altered brain perfusion in patients with MS.  Changes in perfusion may alter the sensitivity and statistical characteristics of fMRI.  Currently, it is unclear to what extent altered tissue perfusion complicates the interpretation of fMRI in MS.  Furthermore, the enhanced activation patterns observed in MS have also been shown in other neurological conditions such as Alzheimer's disease, Parkinson's disease, and stroke.

In a randomized, double-blind, placebo-controlled study, Atri et al (2011) examined the feasibility and test-retest reliability of encoding-task fMRI in mild Alzheimer disease (AD).  These investigators studied 12 patients with mild AD (mean [SEM] Mini-Mental State Examination score, 24.0 [0.7]; mean Clinical Dementia Rating score, 1.0) who had been taking donepezil hydrochloride for more than 6 months from the placebo-arm of a larger 24-week study (n = 24, 4 scans on weeks 0, 6, 12, and 24, respectively).  They performed whole-brain t maps (p < 0.001, 5 contiguous voxels) and hippocampal regions-of-interest analyses of extent (percentage of active voxels) and magnitude (percentage of signal change) for novel-greater-than-repeated face-name contrasts.  These researchers also calculated intra-class correlation coefficients and power estimates for hippocampal regions of interest.  Task tolerability and data yield were high (95 of 96 scans yielded favorable-quality data).  Whole-brain maps were stable.  Right and left hippocampal regions-of-interest intraclass correlation coefficients were 0.59 to 0.87 and 0.67 to 0.74, respectively.  To detect 25.0 % to 50.0 % changes in week-0 to week-12 hippocampal activity using left-right extent or right magnitude with 80.0 % power (2-sided α = 0.05) requires 14 to 51 patients.  Using left magnitude requires 125 patients because of relatively small signal to variance ratios.  The authors concluded that encoding-task fMRI was successfully implemented in a single-site, 24-week, AD randomized controlled trial.  Week 0 to 12 whole-brain t maps were stable, and test-retest reliability of hippocampal fMRI measures ranged from moderate to substantial.  Right hippocampal magnitude may be the most promising of these candidate measures in a leveraged context.  These initial estimates of test-retest reliability and power justify evaluation of encoding-task fMRI as a potential biomarker for signal of effect in exploratory and proof-of-concept trials in mild AD.  They stated that validation of these results with larger sample sizes and assessment in multi-site studies is warranted.

Burgmer and colleagues (2010) stated that studies with functional neuroimaging support the hypothesis of central pain augmentation in fibromyalgia syndrome (FMS) with functional differences in areas of the medial pain system.  These investigators examined if these findings are unique to patients with FMS.  BOLD-signal patterns during and before tonic experimental pain were compared to healthy controls and patients with rheumatoid arthritis (RA) as a chronic pain disorder of somatic origin. These researchers expected different BOLD-signal patterns in areas of the medial pain system that were most pronounced in patients with FMS.  An fMRI-block design before, during and after an incision was performed in patients with FMS (n = 17), RA (n = 16) and in healthy controls (n = 17).  A 2-factorial model of BOLD-signal changes was designed to explore significant differences of brain activation between the groups during the pain stimulus.  Additionally, the correlation of brain activity during the anticipation of pain with the amount of the impending pain was determined.  These researchers observed a FMS-unique temporal brain activation of the frontal cortex in patients with FMS.  Moreover, areas of the motor cortex and the cingulate cortex presented a FMS-specific relation between brain activity during pain anticipation and the magnitude of the subsequent pain experience.  The authors concluded that these findings support the hypothesis that central mechanisms of pain processing in the frontal cortex and cingulate cortex may play an important role in patients with FMS.

Tregellas et al (2010) noted that 3-(2,4-Dimethoxybenzylidene)-anabaseine (DMXB-A) is a partial agonist at alpha7-nicotinic acetylcholine receptors and is now in early clinical development for treatment of deficits in neurocognition and sensory gating in schizophrenia.  During its initial phase II test, fMRI studies were conducted to determine whether the drug had its intended effect on hippocampal inhibitory interneurons.  Increased hemodynamic activity in the hippocampus in schizophrenia is found during many tasks, including smooth pursuit eye movements, and may reflect inhibitory dysfunction.  Placebo and 2 doses of drug were administered in a random, double-blind cross-over design.  After the morning drug/placebo ingestion, subjects underwent fMRI while performing a smooth pursuit eye movement task.  Data were analyzed from 16 non-smoking patients, including 7 women and 9 men.  The 150-mg dose of DMXB-A, compared with placebo, diminished the activity of the hippocampus during pursuit eye movements, but the 75-mg dose was ineffective.  The effect at the 150-mg dose was negatively correlated with plasma drug levels.  The findings are consistent with the previously established function of alpha7-nicotinic receptors on inhibitory interneurons in the hippocampus and with genetic evidence for deficits in these receptors in schizophrenia.  Imaging of drug response is useful in planning future clinical tests of this compound and other nicotinic agonists for schizophrenia.

Astrakas et al (2012) stated that the number of individuals suffering from stroke is increasing daily, and its consequences are a major contributor to invalidity in today's society.  Stroke rehabilitation is relatively new, having been hampered from the long-standing view that lost functions were not recoverable.  Nowadays, robotic devices, which aid by stimulating brain plasticity, can assist in restoring movement compromised by stroke-induced pathological changes in the brain that can be monitored by MRI.  Multi-parametric MRI of stroke patients participating in a training program with a novel Magnetic Resonance Compatible Hand-Induced Robotic Device (MR_CHIROD) could yield a promising biomarker that, ultimately, will enhance the ability to advance hand motor recovery following chronic stroke.  Using state-of-the art MRI in conjunction with MR_CHIROD-assisted therapy can provide novel biomarkers for stroke patient rehabilitation extracted by a meta-analysis of data.  Successful completion of such studies may provide a ground breaking method for the future evaluation of stroke rehabilitation therapies.  Their results will attest to the effectiveness of using MR-compatible hand devices with MRI to provide accurate monitoring during rehabilitative therapy.  Furthermore, such results may identify biomarkers of brain plasticity that can be monitored during stroke patient rehabilitation.  The potential benefit for chronic stroke patients is that rehabilitation may become possible for a longer period of time after stroke than previously thought, unveiling motor skill improvements possible even after 6 months due to retained brain plasticity.

Wager et al (2013) noted that persistent pain is measured by means of self-report, the sole reliance on which hampers diagnosis and treatment.  Functional magnetic resonance imaging holds promise for identifying objective measures of pain, but brain measures that are sensitive and specific to physical pain have not yet been identified.  In 4 studies involving a total of 114 participants, these researchers developed an fMRI-based measure that predicts pain intensity at the level of the individual person.  In study 1, they used machine-learning analyses to identify a pattern of fMRI activity across brain regions -- a neurologic signature -- that was associated with heat-induced pain.  The pattern included the thalamus, the posterior and anterior insulae, the secondary somatosensory cortex, the anterior cingulate cortex, the peri-aqueductal gray matter, and other regions.  In study 2, these investigators tested the sensitivity and specificity of the signature to pain versus warmth in a new sample.  In study 3, they assessed specificity relative to social pain, which activates many of the same brain regions as physical pain.  In study 4, these researchers evaluated the responsiveness of the measure to the analgesic agent remifentanil.  In study 1, the neurologic signature showed sensitivity and specificity of 94 % or more (95 % confidence interval [CI]: 89 to 98) in discriminating painful heat from non-painful warmth, pain anticipation, and pain recall.  In study 2, the signature discriminated between painful heat and non-painful warmth with 93 % sensitivity and specificity (95 % CI: 84 to 100).  In study 3, it discriminated between physical pain and social pain with 85 % sensitivity (95 % CI: 76 to 94) and 73 % specificity (95 % CI, 61 to 84) and with 95 % sensitivity and specificity in a forced-choice test of which of 2 conditions was more painful.  In study 4, the strength of the signature response was substantially reduced when remifentanil was administered.  The authors concluded that it is possible to use fMRI to assess pain elicited by noxious heat in healthy persons.  Moreover, they state that future studies are needed to assess whether the signature predicts clinical pain.

Magland and Childress (2014) stated that real-time fMRI is especially vulnerable to task-correlated movement artifacts because statistical methods normally available in conventional analyses to remove such signals cannot be used in the context of real-time fMRI.  Multi-voxel classifier-based methods, although advantageous in many respects, are particularly sensitive.  These researchers systematically studied various movements of the head and face to determine to what extent these can "masquerade" as signal in multi-voxel classifiers.  A total of 10 subjects were instructed to move systematically (12 instructed movements) throughout fMRI exams and data from a previously published real-time study was also analyzed to determine the extent to which non-neural signals contributed to the high reported accuracy in classifier output.  Of potential concern, whole-brain classifiers based solely on movements exhibited false positives in all cases (p < 0.05).  Artifacts were also observed in the spatial activation maps for 2 of the 12 movement tasks.  In the retrospective analysis, it was determined that the relatively high reported classification accuracies were (fortunately) mostly explainable by neural activity, but that in some cases performance was likely dominated by movements.  The authors concluded that movement tasks of many types (including movements of the body, eyes, and face) can lead to false positives in classifier-based real-time fMRI paradigms.

The University of Michigan Health System’s clinical guideline on “Attention-deficit hyperactivity disorder” (2013) listed functional magnetic resonance imaging as one of the search terms for the update of a previous version of this guideline.  Moreover, the updated guideline stated that “Diagnosis is based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR) criteria.  The three main types are primary hyperactive, primary inattentive, and combined.  No specific test can make the diagnosis”.

Furthermore, UpToDate reviews on “Attention deficit hyperactivity disorder in children and adolescents: Clinical features and evaluation” (Krull, 2014) and “Adult attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis” (Bukstein, 2014) do not mention the use of fMRI as a diagnostic tool.

Wager and colleagues (2013) noted that persistent pain is measured by means of self-report, the sole reliance on which hampers diagnosis and treatment.  Functional MRI holds promise for identifying objective measures of pain, but brain measures that are sensitive and specific to physical pain have not yet been identified.  In 4 studies involving a total of 114 participants, these researchers developed an fMRI-based measure that predicts pain intensity at the level of the individual person.  In study 1, they used machine-learning analyses to identify a pattern of fMRI activity across brain regions -- a neurologic signature -- that was associated with heat-induced pain.  The pattern included the thalamus, the posterior and anterior insulae, the secondary somatosensory cortex, the anterior cingulate cortex, the periaqueductal gray matter, and other regions.  In study 2, these researchers tested the sensitivity and specificity of the signature to pain versus warmth in a new sample.  In study 3, they assessed specificity relative to social pain, which activates many of the same brain regions as physical pain.  In study 4, these investigators assessed the responsiveness of the measure to the analgesic agent remifentanil.  In study 1, the neurologic signature showed sensitivity and specificity of 94 % or more (95 % CI: 89 to 98) in discriminating painful heat from non-painful warmth, pain anticipation, and pain recall.  In study 2, the signature discriminated between painful heat and non-painful warmth with 93 % sensitivity and specificity (95 % CI: 84 to 100).  In study 3, it discriminated between physical pain and social pain with 85 % sensitivity (95 % CI: 76 to 94) and 73 % specificity (95 % CI: 61 to 84) and with 95 % sensitivity and specificity in a forced-choice test of which of 2 conditions was more painful.  In study 4, the strength of the signature response was substantially reduced when remifentanil was administered.  The authors concluded that it is possible to use fMRI to assess pain elicited by noxious heat in healthy persons.  Moreover, they stated that future studies are needed to assess whether the signature predicts clinical pain.

Furthermore, the Work Loss Data Institute’s guideline on “Pain (chronic)” (2013) listed fMRI as one of the interventions that were considered, but are not recommended.

UpToDate reviews on “Locked-in syndrome’ (Caplan, 2015) and “Stupor and coma in adults” (Young, 2015) do not mention functional MRI as a management tool.

Furthermore, an UpToDate review on “Treatment and prognosis of coma in children’ (Thompson and Williams, 2015) states that “Other neuroimaging modalities, MR spectroscopy, functional MRI, positron emission tomography are not useful in the evaluation of coma prognosis]. Studies, awaiting validation, suggest that these tools may help discriminate between persistent vegetative state, minimally conscious state and other states of impaired consciousness”.

Anoxic-Ischemic Brain Injury

An UpToDate review on “Hypoxic-ischemic brain injury: Evaluation and prognosis” (Weinhouse and Young, 2016) states that “In the future, larger studies may find a role for standard MRI as well as functional neuroimaging, such as positron emission tomography (PET) and functional MRI (fMRI), in the prognostic assessment of adults with anoxic-ischemic brain injury …. fMRI studies have the potential to detect network processing of sensory and motor responses, showing some evidence of awareness in a small proportion of behaviorally unresponsive patients.  However, the performance and interpretation of these studies remains complex and is still investigational.  There are also ethical issues regarding quality of life in decision-making that need to be resolved, namely whether patients who can generate such binary responses can participate in a decision-making process”.

Psychotic Depression

O'Connor and Agius (2015) stated that psychotic depression is widely accepted as a specific subtype of unipolar major depression.  Magnetic resonance imaging studies have begun to investigate the neurobiological changes that differentiate this subtype of major depression from non-psychotic depression.  Any differences may eventually be useful in aiding diagnosis patients for whom there is diagnostic uncertainty.  This review collated the currently available evidence.  These investigators performed a systematic search of the Medline, PubMed, Embase & Web of Science databases was used to identify all articles comparing structural grey matter or fMRI differences between adults (18 years or older) with previously diagnosed psychotic and non-psychotic depression in pre-defined regions of interest (hippocampus, amygdala, cingulate, insula and frontal cortices).  The results were collated and organized according to brain region.  There was a paucity of studies addressing structural and functional changes differentiating these 2 disorders and recommendations regarding use of these modalities in diagnosis cannot be made.  From the available studies decreases in frontal cortex grey matter volumes may differentiate psychotic from non-psychotic depression while further studies are needed to confirm decreases in insula cortex volumes.  Functional MRI studies showed associations between altered activity in these 2 regions and cognitive impairments in patients with psychotic depression.  The volumes of putative emotional processing regions including the amygdala, hippocampus and anterior cingulate showed no difference between psychotic and non-psychotic depression.  The authors concluded that structural and functional changes in the higher associative regions of the frontal and insular cortices appeared to differentiate psychotic and non-psychotic depression to a greater degree than changes in putative emotional processing regions.  The quality of the evidence both in terms of numbers of studies available and sample sizes involved was very poor; but in regard to directing future study, understanding the neurobiology of psychotic depression may benefit from a more detailed assessment of these 2 regions.

Temporal Neocortical Epilepsy and Temporal Tumors

On behalf of the American Academy of Neurology (AAN), Szaflarski and colleagues (2017) evaluated the diagnostic accuracy and prognostic value of fMRI in determining lateralization and predicting post-surgical language and memory outcomes.  An 11-member panel rated available evidence according to the 2004 AAN process.  At least 2 panelists reviewed the full text of 172 articles and selected 37 for data extraction.  Case reports, reports with less than 15 cases, meta-analyses, and editorials were excluded.  The authors concluded that the use of fMRI may be considered an option for lateralizing language functions in place of intracarotid amobarbital procedure (IAP) in patients with medial temporal lobe epilepsy (MTLE; Level C), temporal epilepsy in general (Level C), or extra-temporal epilepsy (Level C).  For patients with temporal neocortical epilepsy or temporal tumors, the evidence is insufficient (Level U).  They stated that fMRI may be considered to predict post-surgical language deficits after anterior temporal lobe resection (Level C).  The use of fMRI may be considered for lateralizing memory functions in place of IAP in patients with MTLE (Level C), but is of unclear utility in other epilepsy types (Level U).  Moreover, they stated that fMRI of verbal memory or language encoding should be considered for predicting verbal memory outcome (Level B); and fMRI using non-verbal memory encoding may be considered for predicting visuospatial memory outcomes (Level C).  These investigators noted that pre-surgical fMRI could be an adequate alternative to IAP memory testing for predicting verbal memory outcome (Level C).

Anxiety Disorder

Wang and colleagues (2018) noted that impairments in emotion regulation, and more specifically in cognitive re-appraisal, are thought to play a key role in the pathogenesis of anxiety disorders.  However, the available evidence on such deficits is inconsistent.  To further illustrate the neurobiological underpinnings of anxiety disorder, the present meta-analysis summarized fMRI findings for cognitive re-appraisal tasks and investigated related brain areas.  These investigators performed a comprehensive series of meta-analyses of cognitive reappraisal fMRI studies contrasting patients with anxiety disorder with healthy control (HC) subjects, employing an anisotropic effect-size signed differential mapping approach.  They also conducted a subgroup analysis of medication status, anxiety disorder subtype, data-processing software, and MRI field strengths.  Meta-regression was used to explore the effects of demographics and clinical characteristics.  A total of 8 studies, with 11 datasets including 219 patients with anxiety disorder and 227 HC, were identified.  Compared with HC, patients with anxiety disorder showed relatively decreased activation of the bilateral dorsomedial prefrontal cortex (dmPFC), bilateral dorsal anterior cingulate cortex (dACC), bilateral supplementary motor area (SMA), left ventromedial prefrontal cortex (vmPFC), bilateral parietal cortex, and left fusiform gyrus during cognitive re-appraisal.  The subgroup analysis, jackknife sensitivity analysis, heterogeneity analysis, and Egger's tests further confirmed these findings.  The authors concluded that they identified the most robust functional neuroimaging findings on cognitive re-appraisal in anxiety disorder.  The results demonstrated that patients with anxiety disorder could not recruit the prefronto-parietal network, including the dmPFC, dACC, SMA, vmPFC, and parietal cortex, to down-regulate their emotion response.  These findings provided robust evidence that impairment of prefronto-parietal neuronal circuits may play an important role in the pathogenesis of anxiety disorder.  This finding may provide novel targets for medical or cognitive-behavioral interventions and neuromodulation approaches (e.g., transcranial magnetic stimulation).  These researchers stated that with longitudinal data, future investigations should further explore whether these functional abnormities are associated with structural changes or influenced by disease severity and medication status.

The authors stated that this study had several drawbacks.  First, the number of fMRI studies included was small; the literature search yielded only 8 studies with 11 relevant patients versus controls comparisons.  This could affect the generalizability of these findings, particularly in the subgroup meta-analyses and meta-regressions analyses.  Second, this meta-analysis was based on co-ordinates from published studies rather than raw statistical maps, which might reduce its accuracy.  Third, the heterogeneity of the data acquisition and analysis techniques, including MRI field strengths, slice thickness, voxel size, and data-processing software, may reduce the accuracy of these results.  Fourth, this meta-analysis included studies of medicine-naive patients who had undergone a medication wash-out period before scanning, so that longer-term influences of medication on brain function could not be completely excluded.  Although these researchers conducted a subgroup meta-analysis of the medicine-naive, these results should be interpreted with caution.  Finally, some patients with anxiety disorder had co-morbid major depression.  Anxiety and major depressive disorders may have different disorder-specific deficits in the neural mechanisms of cognitive re-appraisal.  Although the patients fulfilled their criteria for co-morbid major depression with anxiety disorder being the primary diagnosis, the influence of major depression could not be completely ruled out.

Childhood Mal-Treatment

Heany and associates (2018) stated that childhood mal-treatment, including abuse and neglect, may have sustained effects on the integrity and functioning of the brain, alter neurophysiological responsivity later in life, and pre-dispose individuals toward psychiatric conditions involving socio-affective disturbances.  This meta-analysis quantified associations between self-reported childhood mal-treatment and brain function in response to socio-affective cues in adults.  A total of 17 fMRI studies reporting on data from 848 individuals examined with the Childhood Trauma Questionnaire were included in a meta-analysis of whole-brain findings, or a review of region of interest findings.  The spatial consistency of peak activations associated with mal-treatment exposure was tested using activation likelihood estimation, using a threshold of p < 0.05 corrected for multiple comparisons.  Adults exposed to childhood mal-treatment showed significantly increased activation in the left superior frontal gyrus and left middle temporal gyrus, and decreased activation in the left superior parietal lobule and the left hippocampus.  Although hyper-responsivity to socio-affective cues in the amygdala and ventral anterior cingulate cortex in correlation with mal-treatment severity was a replicated finding in region of interest studies, null results were reported as well.  The authors concluded that these findings suggested that childhood mal-treatment had sustained effects on brain function into adulthood, and high-lighted potential mechanisms for conveying vulnerability to development of psychopathology.  These findings need to be further investigated.

Obsessive-Compulsive Disorder

Lu and co-workers (2018) presented a study protocol for a single-blind, randomized controlled trial (RCT) to examine the feasibility and efficacy of mindfulness-based cognitive therapy.  A total of 120 un-medicated Chinese obsessive-compulsive disorder (OCD) patients will be randomized to the mindfulness-based cognitive therapy group, the selective serotonin reuptake inhibitor group or the psycho-education group for 11 sessions in 10 weeks.  A range of scales for clinical symptoms and fMRI will be completed at baseline (week 0), mid-intervention (week 4), post-intervention (week 10) and the 6-month follow-up (weeks 14, 22 and 34).  The authors stated that this study will have relevance to decisions about therapeutic options for un-medicated OCD patients.

Panic Disorder

Ni and colleagues (2020) stated that panic disorder (PD) is a prevalent anxiety disorder, however, its neurobiology remains poorly understood.  It has been proposed that the pathophysiology of PD is related to an abnormality in a particular neural network.  However, most studies investigating resting-state functional connectivity (FC) have relied on a priori restrictions of seed regions, which may bias observations.  These investigators examined changes in intra- and inter-network FC in the whole brain of patients with PD using resting-state fMRI.  A voxel-wise data-driven independent component analysis was performed on 26 PD patients and 27 healthy controls (HCs).  They compared the differences in the intra- and inter-network FC between the 2 groups of subjects using statistical parametric mapping with 2-sample t-tests.  PD patients exhibited decreased intra-network FC in the right anterior cingulate cortex (ACC) of the anterior default mode network, the left pre-central and post-central gyrus of the sensori-motor network, the right lobule V/VI, the cerebellum vermis, and the left lobule VI of the cerebellum network compared with the HCs.  The intra-network FC in the right ACC was negatively correlated with symptom severity.  None of the pairs of resting state networks showed significant differences in functional network connectivity between the 2 groups.  The authors concluded that these results suggested that the brain networks associated with emotion regulation, interoceptive awareness, and fear and somatosensory processing may play an important role in the pathophysiology of PD. 

Furthermore, an UpToDate review on “Panic disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis” (Roy-Byrne, 2020) does not mention functional MRI as a management option.

Psychosis

Gonzalez-Vivas and colleagues (2019) noted that little is known regarding changes in brain functioning after 1st-episode psychosis (FEP).  Such knowledge is important for predicting the course of disease and adapting interventions. and fMRI has become a promising tool for examining brain function at the time of symptom onset and at follow-up.  These researchers carried out a systematic review of longitudinal fMRI studies with FEP patients according to PRISMA guidelines.  Resting-state and task-activated studies were considered together.  A total of 11 studies were included; they reported on a total of 236 FEP patients who were evaluated by 2 fMRI scans and clinical assessments; 5 studies found hypo-activation at baseline in prefrontal cortex areas, 2 studies found hypo-activation in the amygdala and hippocampus, and 3 others found hypo-activation in the basal ganglia.  Other hypo-activated areas were the anterior cingulate cortex, thalamus and posterior cingulate cortex; 10 out of 11 studies reported (partial) normalization by increased activation after anti-psychotic treatment.  A minority of studies observed hyper-activation at baseline.  The authors concluded that this review of longitudinal FEP samples studies showed a pattern of predominantly hypo-activation in several brain areas at baseline that may normalize to a certain extent following treatment.  These investigators stated that these findings should be interpreted with caution given the small number of studies and their methodological and clinical heterogeneity.

Language and Memory Decline (Evaluation After Epilepsy Surgery)

Schmid and colleagues (2018) noted that the European Union-funded E-PILEPSY project was launched to develop guidelines and recommendations for epilepsy surgery.  In a systematic review, these investigators evaluated the diagnostic accuracy of fMRI, Wada test, magnetoencephalography (MEG), and functional transcranial Doppler sonography (fTCD) for language and memory decline after surgery.  They carried out a literature search using PubMed, Embase, and CENTRAL.  The diagnostic accuracy was expressed in terms of sensitivity and specificity for post-operative language or memory decline, as determined by pre- and post-operative neuropsychological assessments.  If 2 or more estimates of sensitivity or specificity were extracted from a study, 2 meta-analyses were conducted, using the maximum ("best case") and the minimum ("worst case") of the extracted estimates, respectively.  A total of 28 papers were eligible for data extraction and further analysis.  All tests for heterogeneity were highly significant, indicating large between-study variability (p < 0.001).  For memory outcomes, meta-analyses were conducted for Wada tests (n = 17) using both memory and language laterality quotients.  In the best case, meta-analyses yielded a sensitivity estimate of 0.79 (95 % CI: 0.67 to 0.92) and a specificity estimate of 0.65 (95 % CI: 0.47 to 0.83).  For the worst case, meta-analyses yielded a sensitivity estimate of 0.65 (95 % CI: 0.48 to 0.82) and a specificity estimate of 0.46 (95 % CI: 0.28 to 0.65).  The overall quality of evidence, which was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, was rated as very low.  Meta-analyses concerning diagnostic accuracy of fMRI, fTCD, and MEG were not feasible due to small numbers of studies (fMRI, n = 4; fTCD, n = 1; MEG, n = 0).  This also applied to studies concerning language outcomes (Wada test, n = 6; fMRI, n = 2; fTCD, n = 1; MEG, n = 0).  The authors concluded that meta-analyses could only be conducted in a few subgroups for the Wada test with low-quality evidence.  Thus, more evidence from high-quality studies and improved data reporting are needed.  Moreover, these researchers stated that the large between-study heterogeneity underlined the necessity for more homogeneous and thus comparable studies in future research.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
70554	Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration
70555	requiring physician or psychologist administration of entire neurofunctional testing
ICD-10 codes covered if selection criteria are met:
C71.0 - C71.9	Malignant neoplasm of brain
C79.31 - C79.49	Secondary malignant neoplasm of brain and other parts of nervous system
D33.0 - D33.2	Benign neoplasm of brain
D43.0 - D43.2, D43.4	Neoplasm of uncertain behavior of brain and spinal cord
G40.001 - G40.919	Epilepsy and recurrent seizures
Q28.2 - Q28.3	Arteriovenous and other malformations of cerebral vessels
R56.1	Post traumatic seizures
R56.9	Unspecified convulsions
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
F20.0 - F20.9 F25.0 - F25.9	Schizophrenia
F29	Unspecified psychosis not due to a substance or known physiological condition
F30.10 - F31.9	Bipolar I disorder
F32.3	Major depressive disorder, single episode, severe with psychotic features
F33.3	Major depressive disorder, recurrent, severe with psychotic symptoms
F41.0 - F41.9	Other anxiety disorders
F42.2 - F42.9	Obsessive-compulsive disorder
F90.1 - F90.9	Attention-deficit hyperactivity disorder,
G20 - G21.9	Parkinson's disease and secondary parkinsonism
G30.0 - G30.9	Alzheimer's disease
G35	Multiple sclerosis
G45.0 - G45.2 G45.4 - G45.9	Transient cerebral ischemic attacks and related syndromes
G89.21 - G89.29	Chronic pain
G93.1	Anoxic brain damage, not elsewhere classified
G93.81 - G93.89	Other specified disorders of brain [Locked-in syndrome]
I63.00 - I66.9	Cerebral infarction, occlusion and stenosis of cerebral and precerebral arteries not resulting in cerebral infarction
I67.1 - I69.998	Cerebovascular diseases and disorders
M79.7	Fibromyalgia
R40.20 - R40.236+	Coma
R40.3	Persistent vegetative state
S01.00x+ - S02.92x+	Open wound of head and fracture of skull and facial bones
S05.20x+ - S05.92x+	Injury of eye and orbit
S06.0x0+ - S06.9x9+	Intracranial injury
S08.0xx+ - S08.89x+	Avulsion and traumatic amputation of part of head
S09.20x+ - S09.90x+	Other and unspecified injuries of head
T74.12xA - T74.12xS	Child physical abuse, confirmed
T74.92xA - T74.92xS	Unspecified child maltreatment, confirmed
T76.12xA - T76.12xS	Child physical abuse, suspected
T76.92xA - T76.92xS	Unspecified child maltreatment

The above policy is based on the following references: