Simple Headache and Dizziness Not Covered by Health Insurance Benefits... Ministry of Health and Welfare Improves Benefit Criteria

MRI image to aid in understanding the article

Going forward, magnetic resonance imaging (MRI) scans for simple headaches and dizziness unrelated to brain diseases such as cerebral hemorrhage and cerebral infarction will be excluded from health insurance coverage. On the 30th, the Ministry of Health and Welfare announced that the 9th Health Insurance Policy Deliberation Committee (HPC) discussed and finalized the 'MRI Appropriate Medical Care Fee Criteria and Review Improvement Plan.'

This is a follow-up measure to the health insurance sustainability enhancement plan announced last February. Since the scope of health insurance coverage expanded to include brain and cerebrovascular MRI scans in October 2018, some medical institutions have claimed health insurance benefits for simple headaches and dizziness, raising the need for improvement. Accordingly, the Ministry of Health and Welfare prepared an MRI examination fee criteria improvement plan based on medical necessity through the 'Fee Criteria Improvement Consultative Group,' which includes professional medical societies.

According to the improvement plan, the health insurance coverage criteria for brain, cerebrovascular, and head and neck MRI scans will be clarified. Previously, health insurance coverage was recognized if only 'cluster headache syndrome' was noted on the brain MRI claim form, but going forward, to be eligible for coverage, 'distinctive neurological abnormal symptoms' must be met. Headaches and dizziness caused by factors such as old age, hypertension, and smoking will be excluded from coverage.

Additionally, the coverage for combined imaging for headaches and dizziness will be reduced from a maximum of three scans to two scans. This follows clinical guidelines recommending no more than two scans for headaches and dizziness. However, in cases where severe brain diseases such as thunderclap headache are suspected and three scans are medically necessary, exceptions will be allowed.

Reviews of medical institutions with frequent inappropriate examinations will also be strengthened. A Ministry of Health and Welfare official explained, "Based on the analysis of insurance claim data, suspicious medical institutions will be selected for focused review."

The MRI fee criteria improvement plan reported to the HPC will be implemented in the second half of the year after administrative notice, revision of the Notification on Criteria for Application of Medical Care Benefits, and a grace period. The Ministry of Health and Welfare stated, "This revision of fee criteria was conducted with the purpose of guaranteeing MRI coverage only in cases where brain disease is suspected or when absolutely necessary."