Blue Cross and Blue Shield of Montana (BCBSMT) may consider magnetic resonance angiography (MRA) and venography (MRV)eligible for coverage when specific criteria outlined below are met:
MRA of the Head:
MRA of the head may be considered medically necessary for the assessment of patients with:
- Suspected steno-occlusive disease of the mid or large size intracranial arteries; OR
- Suspected cerebral aneurysm; OR
- Suspected intracranial vascular malformation; OR
- Suspected cerebral venous sinus compression or thrombosis; OR
- Pulsatile tinnitus.
MRA of the Neck:
MRA of the neck may be considered medically necessary in the assessment of patients suspected of having:
- Carotid stenosis or occlusion; OR
- Cervicocranial arterial dissection.
MRA of the Abdomen or Pelvis:
MRA of the abdomen or pelvis may be considered medically necessary for the assessment of patients with the following clinical indications, in whom angiography would otherwise be indicated, and in whom the result of the MRA would eliminate the need for standard contrast angiography:
- Suspected atherosclerotic renal artery stenosis; OR
- Suspected chronic mesenteric ischemia; OR
- Abdominal aortic aneurysm prior to elective repair of the aneurysm; OR
- Evaluation of the portal and/or hepatic venous system; OR
- Evaluation of the systemic venous system.
MRA of the Pelvis or Lower Extremities:
MRA of the pelvis or lower extremities may be considered medically necessary for the assessment of patients with:
- Suspected atherosclerotic disease of the lower extremity in whom angiography would otherwise be indicated and in whom MRA would eliminate the need for angiography; OR
- Known atherosclerotic disease of the lower extremity who are being evaluated for bypass surgery and in whom angiography fails to identify runoff vessels suitable for bypass.
MRA of Potential Renal Donors:
MRA of potential renal donors may be considered medically necessary to evaluate the presence of accessory renal arteries.
MRA of the Chest (Excluding the Heart):
MRA of the chest (excluding the heart) may be considered medically necessary for patients with any of the following:
- Diagnosis, treatment planning, and postoperative follow-up for conditions of the thoracic aorta such as aneurysm (true or pseudoaneurysm), dissection, or stenotic/occlusive vascular disease; OR
- Diagnosis, treatment planning, and postoperative surgical shunt evaluation in patients with congenital heart disease or developmental anomaly of the thoracic vasculature (e.g., coarctation of the aorta, right-sided aortic arch, double aortic arch, truncus arteriosis, persistent left superior vena cava, interrupted inferior vena cava, total anomalous pulmonary venous connection, partial anomalous venous connection, atresia or hypoplasia of the pulmonary arteries); OR
- Diagnosing systemic venous thrombosis or occlusion; OR
- Diagnosing suspected pulmonary embolus in patients who have a contraindication to the use of intravenous contrast material containing iodine; OR
- As a substitute for pulmonary angiography when a ventilation/perfusion scan does not provide sufficient information for treatment decisions.
MRA of the chest (excluding the heart) is considered not medically necessary for any other condition not listed above.
MRA of the Heart:
MRA of the heart may be considered medically necessary in patients who have a history of severe contrast media allergy to iodine contrast or who are at high risk of contrast-induced renal failure, such as in diabetic patients with moderate renal insufficiency, and in patients for the following:
- Evaluate the anatomy of the valves and to measure regurgitant volume or fraction, ejection fraction (usually performed after echocardiogram); OR
- Measure left and right ventricular volumes; OR
- Assess ventricular septal defects; OR
- Evaluate coronary artery anomaly; OR
- Detect and assess regional wall motion abnormalities; OR
- Assess viability of the myocardium post-myocardial infarction; OR
- Assess asymmetric thickening in certain variants of hypertrophic cardiomyopathy; OR
- Assess for restrictive and constrictive disease when cardiomyopathy is associated with hemochromatosis; OR
- Assess pericardial disease (e.g., constrictive pericarditis, hemopericardium); OR
- Assess cardiac and pericardial masses and tumors; OR
- Assess for intracardiac thrombus.
MRA of the heart is considered not medically necessary for:
- Screening asymptomatic patients for coronary artery disease; OR
- Any other condition not specifically listed as covered above.
MRA of the Spinal Canal:
MRA of the spinal canal is considered experimental, investigational and unproven for any condition.
MRV of the Head:
MRV of the head may be considered medically necessary for the evaluation of patients:
- Suspected of being at risk of thrombus or compression by a tumor of the cerebral venous sinus (e.g., otitis media, meningitis, sinusitis, oral contraceptive use, underlying malignant process, hypercoagulation disorders); OR
- Suspected of having signs or symptoms of thrombus or compression by a tumor of the cerebral venous sinus (e.g., papilledema, focal motor or sensory deficits, seizures, or drowsiness and confusion accompanying a headache).
MRV of the Chest or Abdomen:
MRV of the chest or abdomen may be considered medically necessary for the evaluation of patients suspected of having:
- Venous thrombus or occlusion in the large systemic veins (e.g., superior vena cava, subclavian, or other deep veins of the chest); OR
- Venous thrombus or occlusion in the portal and/or hepatic venous system (e.g., Budd-Chiari Syndrome).
This policy is based on a series of Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessments in 1997, which focused on MRA of the head, neck and abdomen. (1-7), as well as additional information on MRA of the pelvis and lower extremities as a technique to evaluate peripheral vascular disease and MRA of the abdomen for evaluation of potential living renal donors available as of 2003.
MRA of the pelvis and lower extremities has emerged as an important tool for surgical planning, particularly to identify patent run-off vessels when surgical revascularization is considered. (8-11) In addition, MRA has been widely used to evaluate the recurrent symptoms in patients who have undergone either angioplasty or surgical revascularization. A meta-analysis of 34 studies, conducted by Koelemay et al., (12) found that MRA was accurate for identifying stenosis (>50%) or occlusions in the aortic-iliac, femoropopliteal, and infrapopliteal regions. Baum et al. (13) found that MRA is more sensitive for identifying run-off vessels compared with conventional angiography. Use of vessels visible only on MRA for bypass surgery provides an opportunity for limb salvage and when compared with bypass to angiographically, visible vessels, graft-patency and limb-salvage outcomes are similar. (14) These roles of MRA are recognized by the ACR (American College of Radiology) Appropriateness Criteria, found in the ACR Practice Guidelines. (15-16)
Diagnostic performance of MRA of the abdomen for evaluation of renal anatomy in potential living renal donors has improved with the evolution of contrast-enhanced MRA techniques. Recent studies have shown contrast-enhanced MRA to have good sensitivity and specificity for detection of renal arterial and venous anomalies. Three studies reported sensitivity and specificity of 90% or higher for renal arterial anatomy. (17-19) One study examined the ability of contrast-enhanced MRA to detect arterial, venous, ureteral, or parenchymal anomalies during the presurgical evaluation process for laparoscopic nephrectomy. (20) This study found that preoperative MRA agreed completely with surgical findings in 21 of 28 cases (75%). In this study, the laparoscopic surgical procedure was successful in 27 of 28 cases (96%) and only one case required conversion to open nephrectomy, suggesting that some oversights on MRA may not be clinically significant. Furthermore, studies comparing contrast-enhanced MRA to alternatives such as computed tomographic (CT) angiography (CTA) and digital subtraction angiography have reported comparable results. (21-22) However, concerns have been raised regarding the ability of MRA or CTA to detect mild or distal-moderate fibromuscular dysphasia that can be seen on conventional renal angiography. (24) The prevalence of fibromuscular dysphasia is about 2% to 6.6% in angiographic case series, and it is unclear what effect donor nephrectomy may have on the subsequent development of hypertension in asymptomatic potential renal donors who have silent fibromuscular dysphasia. (24)
Additionally, in the initial policy review using the same series of 1997 BCBSA TEC assessments (1-7) indicated earlier, our conclusion was that, compared to angiography, MRA provides:
- A reliable diagnostic assessment of acquired thoracic aortic diseases, vascular anomalies involving the great thoracic arteries and veins; and
- An evaluation of the thoracic, systemic, and central veins for the diagnosis of thrombo-occlusive disease.
However, the evaluation also concluded that diagnostic performance is not sufficiently accurate to allow replacement of pulmonary angiography in the diagnosis of pulmonary embolism (PE) in patients who have no contraindications to receiving intravenous iodinated contrast material. In this setting, MRA may be an acceptable alternative to angiography in patients who are allergic to or who have other contraindications (e.g., renal insufficiency) for iodinated contrast media. (1-7)
It should be noted that in all applications, MRA is considered an alternative to angiography. A 2003 review did not identify any published articles that addressed the limitations noted in the series of BCBSA TEC Assessments; therefore, the policy statement is unchanged. Specifically, the appropriateness criteria of the ACR are consistent with the conclusions of the BCBSA TEC Assessment. For example, the ACR appropriateness criteria offer the following statement regarding MRA in a patient with suspected PE, “MRA is not indicated in the routine evaluation of patients with suspected pulmonary embolism…currently it is mainly used in certain centers with particular interest and expertise, and in patients in whom contrast administered for helical CT scans or even for pulmonary angiography is thought to be contraindicated.…” (15-16)
Literature was searched for the period of 2003 through March 2006, with a particular focus on MRA of the chest to detect PE and on MRA of the heart. MRA would only be indicated in the subset of patients that have a contraindication to contrast media containing iodine. When indicated, the administration of intravenous MRI or MRA contrast agent (Gadolinium chelate) is associated with an overall lower nephrotoxicity and allergic response when compared with radiographic use of intravascular iodinated contrast material during CT examinations. Contrast utilization is at the discretion of the ordering and imaging providers. (16)
A literature search of MedLine database was performed through August 2008. No articles were identified that would change the coverage position of this medical policy.
A search of peer reviewed literature through September 2010 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.
A search of peer reviewed literature through June 2012, including a review of the current ACR Appropriateness Criteria, found in the ACR Practice Guidelines (25-27), identified no new clinical trial publications or any additional information, that would change the coverage position of this medical policy.
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Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.