Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Guided Functional Ultrasound 
High Intensity Focused Ultrasound (MRgFUS), stereotactic ablation (CPT 0398T). 
 
You asked the Plan to pre-approve Magnetic Resonance Guided Functional Ultrasound High Intensity Focused 
Ultrasound (MRgFUS), stereotactic ablation. The Plan denied your request. The Plan says the member is a 
candidate for treatment using Deep Brain Stimulation (DBS) and Medicare policy reserves the MRgFUS 
stereotactic ablation for those patients who are not a candidate for the other treatment. 
 
The Plan follows Medicare rules. Medicare rules say that magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS) is for the treatment of idiopathic essential tremor patients with medication-
refractory tremor. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Magnetic Resonance Guided Functional 
Ultrasound High Intensity Focused Ultrasound (MRgFUS), stereotactic ablation. Our reviewer says that 
MRgFUS is not medically necessary. Our physician reviewer found that the enrollee is a  66 year old male with 
a history of colitis, IBS, difficult airway for intubation (unable to pass ETT x 3 when needed anesthesia for 
MRI of head; used LMA), OA, other dysphagia and person use of ETOH (15 beers /week), who is followed for 
a hand tremor present since 1969 which has worsened over time. Approximately 10 years ago he started taking 
medication for tremor in B hand which occurs only with activities and interferes with eating/drinking and 
dressing. The enrollee denies gait difficulty and memory issues. The enroll had been considered good candidate 
for DBS surgery and underwent evaluation, however, procedure was delayed due to chest congestion. The 
enrollee was deemed to be a good candidate for DBS, but this procedure was delayed due to chest congestion 
(later determined to be asthma). Additionally of concern is that this enrollee underwent an evaluation at another 
institution for the MRgFUS and was deemed to not be a good candidate due to skull density being lower than 
established guidelines. In another clinical note submitted, it was stated that his skull density is 0.37 and the 
minimal requirement is 0.4 but that KU might do with a density as low as 0.34. This is not discussed in their 
records submission as to why they are deviating from the accepted standards and is of concern as a separate 
issue. In conclusion, this enrollee has been deemed to be a good candidate for DBS and therefore, MRgFUS is 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Magnetic Resonance Guided Functional Ultrasound High Intensity Focused 
Ultrasound (MRgFUS), stereotactic ablation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Magnetic Resonance Guided Functional Ultrasound High Intensity Focused Ultrasound 
(MRgFUS), stereotactic ablation (CPT 0398T).