This document addresses the use of positional (non-recumbent) magnetic resonance imaging (MRI), which is an imaging technique where an individual has an MRI while placed in specific weight bearing positions or during movement of the anatomy of interest.  It has been proposed that such images provide data which standard MRI images cannot.

Note:  For more information regarding specialized MRI devices, please see:

• RAD.00049 Low Field and Conventional Magnetic Resonance Imaging (MRI) for Screening, Diagnosing and Monitoring
• RAD.00051 Functional Magnetic Resonance Imaging (fMRI)

Investigational and Not Medically Necessary:

Positional (non-recumbent) magnetic resonance imaging (MRI), including but not limited to, standing, sitting or dynamic-kinetic MRI imaging, is considered investigational and not medically necessary for all indications, including but not limited to, spine, knee and pelvic conditions.

Positional MRI has become an option used by some physicians to diagnose spinal, knee and pelvic conditions.  A search of the PubMed database located a limited number of clinical trials related to positional MRI procedures.  These studies addressed knee pain (Besier, 2005; Gold, 2004; Tennant 2001), pelvic floor muscle laxity (Bo, 2001; Gufler, 2004; Law, 2001), and back pain (Jarvik. 2001; Jinkins, 2005; Jorgensen, 2005; Schmid, 1999; Vitaz, 2004; Weishaupt, 2003; Weishaupt, 2000; Wildermuth, 1998; Zamani, 1998, Ferreiro Perez, 2007).  The vast majority of these studies included very small study populations.

A number of these studies have reported that positional MRI can identify abnormalities in individuals where conventional MRI did not identify significant abnormal findings.  Weishaupt (2000) and colleagues reported finding 13 instances of nerve root deviation in the seated extension position compared with 10 instances in the supine position in a group of 30 subjects with chronic low back pain.  They also reported that positional pain score differences were related to foraminal size.  Vitaz (2004) reported changes in spinal cord compression, angulation, and alignment that occurred during physiologic movement in 20 subjects with cervical spine disorders.  They reported excellent or good image quality in 90% of cases.  Finally, Jinkins (2005) concluded that supine MRI underestimated the presence and degree of gravity-dependent spinal pathology and missed pathology of a dynamic nature.  None of these studies provided any data regarding the impact of positional MRI on outcomes.

The Washington State Health Care Authority produced a technology assessment report on the effectiveness of upright MRI for evaluation of individuals with suspected spinal or extra-spinal joint dysfunction (Skelly, 2007).  This report describes the overall quality of the available literature comparing upright MRI (uMRI) with other available diagnostic methods.  Conclusions drawn from this technology assessment included:

• Only limited evidence (overall strength of evidence is low) is available to suggest that uMRI provides similar diagnostic information compared with conventional recumbent (rMRI) with respect to disc pathology and foraminal stenosis of the lumbar spine.
• No evidence is available to determine test characteristics of sensitivity, specificity and predictive values or likelihood ratios based upon comparison with the gold standard of upright myelogram combined with CT myelogram.
• Evidence for concordance between rMRI and uMRI is very low with respect to cervical disc herniation, lumbar nerve root compromise, and spondylolisthesis.
• There is some indication that the seated position in uMRI is not tolerated well in a number of individuals with lumbar pathology, preventing the imaging exam from proceeding.   

In addition, there were no studies found that met level of evidence inclusion criteria for the evaluation of uMRI of the hip, knee or ankle.

A study by Kanno and associates reported the findings of a study of 44 consecutive subjects who underwent imaging with conventional MRI, axial MRI and upright myelogram (2011).  The measurements of the transverse and anteroposterior diameters, as well as the cross sectional areas of the dural sac from L2/3 to L5/S1 from all three imaging methods were compared.  The authors reported that results from axial loaded MRI demonstrated a significant reduction in the dural sac size and significant correlations of the dural sac diameters with the upright myelogram (p < 0.001).  Furthermore, the axial loaded MRI had higher sensitivity and specificity than the conventional MRI for detecting the severe constriction observed in the myelogram (96.4% vs. 83.9% and 98.2% vs. 87.0%, respectively).  While these findings are promising, further investigation into how axial MRI can improve health outcomes compared to conventional MRI is warranted.

It must be noted that although an MRI image may identify anatomic abnormalities, the correlation between radiographic findings and issues of clinical significance may be uncertain (Jarvik 2001).  At this time no studies have been published correlating positional MRI findings with a significant impact on clinical decision making and health outcome, particularly in individuals with normal recumbent MRI studies.  Larger controlled studies are needed to address these issues.  There is currently insufficient evidence to demonstrate that positional MRI offers any advantages over conventional MRI methods.

Conventional magnetic resonance images (MRI) are taken with the person in a recumbent or supine position.  Positional MRI has recently been proposed as a means by which MRIs may be taken with the anatomic area of interest bearing weight or in a position that causes the symptoms (standing, sitting, or moving).  This method has been suggested as an improved means by which various conditions can be diagnosed and managed, including spine or knee pain, and conditions related to pelvic floor weakness.

Positional MRIs involve the use of newer lower magnet strength MRI machines which have an "open" configuration, allowing imaging of the person in various positions.  The imaging can be conducted with partial or full weight bearing on the knee, hip, spine, etc. and may also allow "dynamic-kinetic imaging" where images are obtained during movement.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When Services are Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Besier TF, Draper CE, Gold GE, et al. Patellofemoral joint contact area increases with knee flexion and weight-bearing. J Orthopaedic Res. 2005; 23(2):345-350.
2. Bo K, Lilleas F, Talseth T, Hedland H. Dynamic MRI of the pelvic floor muscles in an upright sitting position. Neurourol Urodyn. 2001; 20(2):167-174.
3. Ferreiro Perez A, Garcia Isidro M, Ayerbe E, et al. Evaluation of intervertebral disc herniation and hypermobile intersegmental instability in symptomatic adult patients undergoing recumbent and upright MRI of the cervical or lumbosacral spines. Eur J Radiol. 2007; 62(3):444-448.
4. Gold GE, Besier TF, Draper CE, et al.  Weight-bearing MRI of patellofemoral joint cartilage contact area. J Magn Reson Imaging. 2004; 20(3):526-530.
5. Gufler H, Ohde A, Grau G, Grossmann A.  Colpocystoproctography in the upright and supine positions correlated with dynamic MRI of the pelvic floor. Eur J Radiol. 2004; 51(1):41-47.
6. Jarvik JJ, Hollingworth W, Heagerty P, et al. The longitudinal assessment of imaging and disability of the back (LAIDBack) Study: baseline data. Spine. 2001; 26(10):1158-1166. 
7. Jinkins JR, Dworkin JS, Damadian RV. Upright, weight-bearing, dynamic-kinetic MRI of the spine: initial results. Eur Radiol. 2005; 15(9):1815-1825.
8. Jorgensen MJ, Marras WS, Smith FW, Pope MH.   Sagittal plane moment arms of the female lumbar region rectus abdominis in an upright neutral torso posture. Clin Biomech. 2005; 20(3):242-246.
9. Kanno H, Endo T, Ozawa H, et al. Axial loading during magnetic resonance imaging in patients with lumbar spinal canal stenosis: does it reproduce the positional change of the dural sac detected by upright myelography? Spine (Phila Pa 1976). 2011 Jan 20. [Epub ahead of print]
10. Law PA, Danin JC, Lamb GM, et al.  Dynamic imaging of the pelvic floor using an open-configuration magnetic resonance scanner. J Magn Reson Imaging. 2001; 13(6):923-929.
11. Schmid MR, Stucki G, Duewell S, et al. Changes in cross-sectional measurements of the spinal canal and intervertebral foramina as a function of body position: in vivo studies on an open-configuration MR system. AJR Am J Roentgenol. 1999; 172(4):1095-1102.
12. Tennant S, Williams A, Vedi V, et al.  Patello-femoral tracking in the weight-bearing knee: a study of asymptomatic volunteers utilising dynamic magnetic resonance imaging: a preliminary report. Knee Surg Sports Traumatol Arthrosc. 2001; 9(3):155-162.
13. Vitaz TW, Shields CB, Raque GH, et al. Dynamic weight-bearing cervical magnetic resonance imaging: technical review and preliminary results. South Med J. 2004; 97(5):456-446.
14. Weishaupt D, Boxheimer L.  Magnetic resonance imaging of the weight-bearing spine. Semin Musculoskelet Radiol. 2003; 7(4):277-786.
15. Weishaupt D, Schmid MR, Zanetti M, et al. Positional MR imaging of the lumbar spine: does it demonstrate nerve root compromise not visible at conventional MR imaging? Radiology. 2000; 215(1):247-253.
16. Wildermuth S, Zanetti M, Duewell S, et al.  Lumbar spine: quantitative and qualitative assessment of positional (upright flexion and extension) MR imaging and myelography. Radiology. 1998; 207(2):391-398.
17. Zamani AA, Moriarty T, Hsu L, et al.  Functional MRI of the lumbar spine in erect position in a superconducting open-configuration MR system: preliminary results. J Magn Reson Imaging. 1998; 8(6):1329-1333.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. National Coverage Determination for Magnetic Resonance Imaging. NCD #220.2. Effective February 24, 2011. Available at:  http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd.  Accessed on March 22, 2011.
2. Skelly AC, Moore E, Dettori JR.  Comprehensive evidence-based health technology assessment: Effectiveness of upright MRI for evaluation of patients with suspected spinal or extra-spinal joint dysfunction. Washington State Health Care Authority. May 11, 2007. Available at: http://www.hta.hca.wa.gov/documents/uMRI_final_report.pdf. Accessed on March 8, 2011.

Dynamic-Kinetic Imaging
FONAR 360º Magnetic Resonance Imaging Scanner
GE 0.35T Signa^® Ovation with Excite Magnetic Resonance System
Indomitable Magnetic Resonance Imaging Scanner
Positional Magnetic Resonance Imaging
Positional MRI
Upright MRI™

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.