GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy
When a separate MRA and MRI exam is requested, documentation requires a medical reason that clearly indicates why additional MRI imaging of the lower extremity is needed.

Lower extremity MRA and abdomen/pelvis magnetic resonance angiography (MRA) runoff requests: Two authorization requests are required, one abdomen MRA, CPT code 74185, and one for lower extremity MRA, CPT code 73725. This will provide imaging of the abdomen, pelvis, and both legs. 

INDICATIONS FOR LOWER EXTREMITY MRA/MRV
Peripheral Vascular Disease

• Critical Limb ischemia ANY of the below with clinical signs of peripheral artery disease. Ultrasound imaging is not needed. If done and negative, it should still be approved due to high false negative rate^1,2
  • Ischemic rest pain
  • Tissue loss
  • Gangrene
• Claudication with abnormal or indeterminate ankle/brachial index, pulse volume recording or arterial Doppler^3,4,5
• Clinical concern for vascular cause of ulcers with abnormal or indeterminate ultrasound (ankle/brachial index, arterial Doppler)⁶
• After stenting or surgery with signs of recurrent symptoms OR abnormal ankle/brachial index; abnormal or indeterminate arterial Doppler, OR pulse volume recording)⁴

Popliteal artery entrapment syndrome with abnormal arterial ultrasound⁷

Deep venous thrombosis with clinical suspicion of lower extremity DVT after abnormal or non-diagnostic ultrasound where a positive study would change management^8,9,10

Clinical suspicion of vascular disease with abnormal or indeterminate ultrasound or other imaging

• Tumor invasion^11,12
• Trauma¹³
• Vasculitis¹⁴
• Aneurysm¹⁵
• Stenosis/occlusions¹⁶

Hemodialysis graft dysfunction, after Doppler ultrasound not adequate¹⁷ for treatment decisions¹⁸

Vascular malformation^18,19

• After initial evaluation with ultrasound and results will change management OR
• Inconclusive ultrasound OR
• For preoperative planning
  • MRI is also approvable for initial evaluation

Traumatic injuries with clinical findings suggestive of arterial injury — CTA preferred emergently¹³

Assessment/evaluation of suspected or known vascular disease/condition

Pre-operative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure³

Post-operative/procedural evaluation

• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.^20,21

Special Circumstances²

• High suspicion of an acute arterial obstruction — Arteriography preferred (the gold standard). 
• Renal impairment 
  • Not on dialysis
    • Mild to moderate, GFR 30 – 45 ml/min MRA with contrast can be performed
    • Severe, GFR < 30 ml/min MRA without contrast 
  • On dialysis 
    • CTA with contrast can be done 
• Doppler ultrasound can be useful in evaluating bypass grafts

Rationale
Magnetic resonance angiography (MRA) is a noninvasive alternative to catheter angiography for evaluation of vascular structures in the lower extremity. Magnetic resonance venography (MRV) is used to image veins instead of arteries. MRA and MRV are less invasive than conventional X-ray digital subtraction angiography. 

OVERVIEW
Noninvasive testing — noninvasive hemodynamic testing — “Noninvasive testing (NIVT), both before and after intervention, has been used for decades as a first-line investigatory tool in the diagnosis and categorization of PAD. It is widely available and provides a large amount of information at low cost without the use of ionizing radiation. NIVT can consist of one or more of the following components: the ABI, segmental pressure measurements (SPMs), pulse-volume recordings (PVRs), photoplethysmography (PPG), and transcutaneous oxygen pressure measurement (TcPO2).”21 The ankle- brachial index (ABI) is the ratio of systolic blood pressure at the ankle divided by the systolic pressure of the upper arm. The normal range lies between 0.9-1.4. An ABI of less than 0.9 is a reliable indicator of the presence of lower extremity PAD, indicating athero-occlusive arterial disease. The upper limit of normal ABI should not exceed 1.40. An ABI > 1.40 is suggestive of arterial stiffening (i.e., medial arterial calcification) and is also associated with a higher risk of cardiovascular events and is seen in elderly patients, typically in those with diabetes or chronic kidney disease (CKD).

References

1. Shishehbor MH, White CJ, Gray BH, et al. Critical Limb Ischemia: An Expert Statement. J Am Coll Cardiol. Nov 1 2016;68(18):2002-2015. doi:10.1016/j.jacc.2016.04.071
2. Weiss CR, Azene EM, Majdalany BS, et al. ACR Appropriateness Criteria(®) Sudden Onset of Cold, Painful Leg. J Am Coll Radiol. May 2017;14(5s):S307-s313. doi:10.1016/j.jacr.2017.02.015
3. Ahmed O, Hanley M, Bennett SJ, et al. ACR Appropriateness Criteria(®) Vascular Claudication-Assessment for Revascularization. J Am Coll Radiol. May 2017;14(5s):S372-s379. doi:10.1016/j.jacr.2017.02.037
4. Pollak AW, Norton PT, Kramer CM. Multimodality imaging of lower extremity peripheral arterial disease: current role and future directions. Circ Cardiovasc Imaging. Nov 2012;5(6):797-807. doi:10.1161/circimaging.111.970814
5. Pollak AW, Kramer CM. MRI in Lower Extremity Peripheral Arterial Disease: Recent Advancements. Curr Cardiovasc Imaging Rep. Feb 1 2013;6(1):55-60. doi:10.1007/s12410-012-9175-z
6. Rosyid FN. Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer. Int J Res Med Sci. 2017;5(10):4206-13. doi:http://dx.doi.org/10.18203/2320-6012.ijrms20174548
7. Williams C, Kennedy D, Bastian-Jordan M, Hislop M, Cramp B, Dhupelia S. A new diagnostic approach to popliteal artery entrapment syndrome. J Med Radiat Sci. Sep 2015;62(3):226-9. doi:10.1002/jmrs.121
8. American College of Radiology. ACR Appropriateness Criteria® Suspected Lower Extremity Deep Vein Thrombosis. American College of Radiology. Updated 2018. Accessed January 23, 2023. https://acsearch.acr.org/docs/69416/Narrative/
9. Karande GY, Hedgire SS, Sanchez Y, et al. Advanced imaging in acute and chronic deep vein thrombosis. Cardiovasc Diagn Ther. Dec 2016;6(6):493-507. doi:10.21037/cdt.2016.12.06
10. Katz DS, Fruauff K, Kranz A-O, Hon M. Imaging of deep venous thrombosis: A multimodality overview. Applied Radiology, Anderson Publishing. Updated March 5, 2014. Accessed January 23, 2023. https://www.appliedradiology.com/articles/imaging-of-deep-venous-thrombosis-a-multimodality-overview
11. Jin T, Wu G, Li X, Feng X. Evaluation of vascular invasion in patients with musculoskeletal tumors of lower extremities: use of time-resolved 3D MR angiography at 3-T. Acta Radiol. May 2018;59(5):586-592. doi:10.1177/0284185117729185
12. Kransdorf MJ, Murphey MD, Wessell DE, et al. ACR Appropriateness Criteria(®) Soft-Tissue Masses. J Am Coll Radiol. May 2018;15(5s):S189-s197. doi:10.1016/j.jacr.2018.03.012
13. Wani ML, Ahangar AG, Ganie FA, Wani SN, Wani NU. Vascular injuries: trends in management. Trauma Mon. Summer 2012;17(2):266-9. doi:10.5812/traumamon.6238
14. Fonseka CL, Galappaththi SR, Abeyaratne D, Tissera N, Wijayaratne L. A Case of Polyarteritis Nodosa Presenting as Rapidly Progressing Intermittent Claudication of Right Leg. Case Rep Med. 2017;2017:4219718. doi:10.1155/2017/4219718
15. Verikokos C, Karaolanis G, Doulaptsis M, et al. Giant popliteal artery aneurysm: case report and review of the literature. Case Rep Vasc Med. 2014;2014:780561. doi:10.1155/2014/780561
16. Menke J, Larsen J. Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease. Ann Intern Med. Sep 7 2010;153(5):325-34. doi:10.7326/0003-4819-153-5-201009070-00007
17. Richarz S, Isaak A, Aschwanden M, Partovi S, Staub D. Pre-procedure imaging planning for dialysis access in patients with end-stage renal disease using ultrasound and upper extremity computed tomography angiography: a narrative review. Cardiovascular Diagnosis and Therapy. 2022;13(1):122-132. 
18. Madani H, Farrant J, Chhaya N, et al. Peripheral limb vascular malformations: an update of appropriate imaging and treatment options of a challenging condition. Br J Radiol. Mar 2015;88(1047):20140406. doi:10.1259/bjr.20140406
19. Obara P, McCool J, Kalva SP, et al. ACR Appropriateness Criteria® Clinically Suspected Vascular Malformation of the Extremities. J Am Coll Radiol. Nov  2019;16(11s):S340-s347. doi:10.1016/j.jacr.2019.05.013
20. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. Jun 2019;69(6s):3S-125S.e40. 
21. doi:10.1016/j.jvs.2019.02.016
22. Cooper K, Majdalany BS, Kalva SP, et al. ACR Appropriateness Criteria(®) Lower Extremity Arterial Revascularization-Post-Therapy Imaging. J Am Coll Radiol. May 2018;15(5s):S104-s115. doi:10.1016/j.jacr.2018.03.011

Coding Section 

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.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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