MR Angiography Chest - CAM 762

Policy:
INDICATIONS FOR CHEST MRA
Chest Magnetic Resonance Angiography (MRA) is ordered for evaluation of the intrathoracic blood vessels. Chest MRI and Chest MRA should not be approved at the same time.

Vascular Disease

  • Superior vena cava (SVC) syndrome (Friedman, 2017)
  • Subclavian Steal Syndrome after positive or inconclusive ultrasound (Osiro, 2012; Potter, 2014)
  • Thoracic Outlet Syndrome (ACR, 2014; Chavhan, 2017; Povlsen, 2018)
  • Takayasu’s arteritis (Keser, 2014)
  • Clinical concern for acute aortic dissection (ACR, 2017; Barman, 2014)
    • Sudden painful ripping sensation in the chest or back and may include
      • New diastolic murmur
      • Cardiac tamponade
      • Distant heart sounds
      • Hypotension or shock
  • For MRPA (MR Pulmonary Angiography) in patients with intermediate pretest probability with a positive D-dimer or high pretest probability (but only at centers that routinely perform it well and only for patients for whom standard tests are contraindicated)
    • Risk can be determined by the parameters detailed in Background section

Initial/Screening for Thoracic Aortic Disease
(Erbel, 2014; Hannuksela, 2015; Hiratzka, 2010)

  • Echocardiogram or chest x-ray show aneurysm
  • Screening of first-degree relatives of individuals with a thoracic aortic aneurysm (defined as > 50% above normal) or dissection
    • Known connective tissue disease or genetic conditions that predispose to aortic aneurysm or dissection (e.g., Marfan syndrome, Ehlers Danlos or Loeys-Dietz syndromes)
  • Screening of the thoracic aorta after a diagnosis of a bicuspid aortic valve (dilation of the ascending aorta may not be seen on echocardiogram) (Borger,2018; Verma, 2014)
    • If normal, reimage every three to five years  
  • Screening of first-degree relatives of patients with a bicuspid aortic valve
  • Turner’s syndrome – Screen for coarctation or aneurysm of the thoracic aorta 
    • If normal results, screen every 5-10 years
    • If abnormal, screen annually
  • Suspected vascular cause of dysphagia or expiratory wheezing with other imaging is suggestive or inconclusive

Follow-up after established Thoracic Aneurysm
(Erbel, 2014; Hannuksela 2015; Hiratzka, 2010)

  • Six months follow-up after initial finding of a dilated thoracic aorta, for assessment of rate of change
    • Aortic Root or Ascending Aorta
      • 3.5 to 4.4 Annual
      • 4.5 to 5.5 or growth rate > 0.5 cm/year - Every 6 months
    • Genetically mediated (Marfans syndrome, Aortic Root or Ascending Aorta) 
      • 3.5 to 4.4 Annual
      • 4.5 to 5.0 or growth rate > 0.5 cm/year Every 6 months
      • Surgery generally recommended over 5.0 cm
    • Descending Aorta (Braverman, 2011)
      • 4.0 to 5.0 Annual
      • 5.0 to 6.0 Every 6 months
  • Follow-up post medical treatment of aortic dissection
    • Acute dissection: 1 month, 6 months, then annually
    • Chronic dissection: annually
  • Follow-up post either root repair or AVR plus ascending aortic root/arch repair: baseline post-op, then annually
  • Re-evaluation of known ascending aortic dilation or history of aortic dissection with a change in clinical status or cardiac exam or when findings may alter management

Congenital Malformations

  • Thoracic malformation on other imaging (chest x-ray, echocardiogram, gastrointestinal study, or inconclusive CT) (Ferreira, 2015; Hellinger, 2011; Karaosmanoglu, 2015; Poletto, 2017)
  • Congenital heart disease with pulmonary hypertension (Pascall, 2018) or vascular anomalies
  • Pulmonary Sequestration (Sancak, 2003)

Pulmonary Hypertension based on other testing
(Ascha, 2017; Rose-Jones, 2015)

  • Echocardiogram
  • Right heart catheterization

Atrial fibrillation with ablation planned
(Kolandaivelu, 2012)

Pre-operative/procedural evaluation

  • Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation

  • Post-operative complications (Bennet, 2017; Choudhury, 2017)
  • Routine post-operative (Lawrence; 2018; Uthof, 2012)
    • Thoracic endovascular or open surgical aneurysm repair
      • 1 month
      • More frequent follow-up/possible intervention if complication detected
      • If stable, annual for 5 years

Chest MRA and Abdomen MRA or Abdomen/Pelvis MRA

  • Acute aortic dissection (Barman, 2014)
  • Takayasu’s arteritis (Keser, 2014)

Background 
Magnetic resonance angiography (MRA) is a noninvasive technique used to provide cross-sectional and projection images of the thoracic vasculature, including large- and medium-sized vessels, e.g., the thoracic aorta. MRA provides images of both normal and diseased blood vessels, and it quantifies blood flow through these vessels. Successful vascular depiction relies on the proper imaging pulse sequences. MRA may use a contrast agent, gadolinium, which is non-iodine-based, for better visualization. It can be used in patients who have history of contrast allergy and who are at high risk of kidney failure.

OVERVIEW
MRA and Coarctation of the Aorta One of the most common congenital vascular anomalies is coarctation of the aorta which is characterized by obstruction of the juxtaductal aorta. Clinical symptoms, e.g., murmur, systemic hypertension, difference in blood pressure in upper and lower extremities, absent femoral or pedal pulses, may be present. Gadolinium-enhanced 3D MRA may assist in preoperative planning as it provides angiographic viewing of the aorta, the arch vessels, and collateral vessels. It may also assist in the identification of postoperative complications.

MRA and Pulmonary Embolism (PE) Note: D-Dimer blood test in patients at low risk* for DVT is indicated prior to MRA imaging. Negative D-Dimer suggests alternative diagnosis in these patients.  

Low risk is not approved. Low risk is defined as NO to ALL of the following questions with intermediate and high risk defined based on the number of positive responses (Konstantinides, 2014):

  • Evidence of current or prior DVT;
  • HR > 100;
  • Cancer diagnosis;
  • Recent surgery or prolonged immobilization;
  • Hemoptysis;
  • History of PE;
  • Oral hormone use;
  • Another diagnosis beside PE is less likely

Studies show mixed results regarding the value of MRA versus CTA in detecting pulmonary embolism. A systematic review and meta-analysis found MRA to be inferior to CTA in detecting PE. Therefore, MRA should be used only if CTA is not available or contraindicated in a specific patient (Li, 2016).

MRA and Thoracic Aortic Aneurysm – One of the most common indications for thoracic MRA is thoracic aortic aneurysm, most often caused by atherosclerosis. These aneurysms may also be due to aortic valvular disease. Aneurysms are defined by their enlargement and patients with rapidly expanding aortas, or with aortic diameters greater than five or six centimeters, are at high risk of rupture and may require surgery.

MRA and Thoracic Aortic Dissection – The most common clinical symptom of aortic dissection is tearing chest pain and the most common risk factor is hypertension. An intimal tear is the hallmark for aortic dissection and intramural hematoma may also be detected. Unfortunately, patients with aortic dissection may be unstable and not good candidates for routine MR evaluation; MRA may be indicated as a secondary study. 3D MRA is also useful in postoperative evaluation of patients with repaired aortic dissections.

MRA and Central Venous Thrombosis – MRA is useful in the identification of venous thrombi. Venous thrombosis can be evaluated by gadolinium-enhanced 3D MRA as an alternative to CTA, which may not be clinically feasible due to allergy to iodine contrast media or renal insufficiency.

Other MRA Indications – MRA is useful in the assessment for postoperative complications of pulmonary venous stenosis.

MRI and Patent Ductus Arteriosus – Patent ductus arteriosus (PDA) is a congenital heart problem in which the ductus arteriosus does not close after birth. It remains patent allowing oxygen-rich blood from the aorta to mix with oxygen-poor blood from the pulmonary artery. MRI can depict the precise anatomy of a PDA to aid in clinical decisions. It allows imaging in multiple planes without a need for contrast administration. Patients are not exposed to ionizing radiation.

References:

  1. American College of Chest Physicians (ACCP). Choosing Wisely®: Five Things Physicians and Patients Should Question. ACCP. 2013. Retrieved from http://www.choosingwisely.org/clinician-lists/american-college-chest-physicians-american-thoracic-society-chest-ct-angiography-to-evaluate-possibly-pulmonary-embolism/.
  2. American College of Radiology (ACR). ACR Appropriateness Criteria®. Published 2014. Revised 2016. Retrieved from https://acsearch.acr.org/list.
  3. American College of Radiology (ACR). ACR Appropriateness Criteria®. https://acsearch.acr.org/list. Published 2017. Retrieved from March 16, 2018.
  4. Ascha M, Renapurkar RD, Tonelli AR. A review of imaging modalities in pulmonary hypertension. Ann Thorac Med. 2017; 12(2):61–73.
  5. Barman M. Acute aortic dissection.E-Journal European Society of Cardiology. 2014;12: N° 25 – 02.
  6. Bauer AM, Amin-Hanjani S, Alarj A, et al. Quantitative magnetic resonance angiography in the evaluation of the subclavian steal syndrome: Report of 5 patients. J Neuroimaging. 2009; 19:250-252.
  7. Bennet KM, Kent KC, Schumaker J, et al. Targeting the most important complications in vascular surgery. J Vasc Surg. 2017;65(3):793-803.
  8. Bonci G, Steigner ML, Hanley M, et al. ACR Appropriateness Criteria®. Thoracic Aorta Interventional Planning and Follow-up. J Am Coll Radiol. 2017; 14(11S):S570-S583.
  9. Borger MA, Fedak PWM, Stephens EH, et al. The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Full online-only version. J Thorac Cardiovasc Surg. 2018;156(2):e41-e74. doi:10.1016/j.jtcvs.2018.02.115.
  10. Braverman A, Thompson R, Sanchez L. Diseases of the aorta. In: Braunwald’s heart disease, 9th ed, Bonow R, Mann D, Zipes D, Libby P (Eds), Elsevier, Philadelphia 2011. p.1309.  
  11. Chavhan GB, Batmanabane V, Muthusami P, et al. MRI of thoracic outlet syndrome in children. Pediatr Radiol. 2017; 47:1222-1234.
  12. Choudhury M. Postoperative Management of Vascular Surgery Patients: A Brief Review. Clin Surg. 2017; 2: 1584.
  13. Corrigan D, Prucnal C, Kabrhel C. Pulmonary embolism: the diagnosis, risk-stratification, treatment and disposition of emergency department patients. Clin Exp Emerg Med. 2016; 3(3): 117–125.
  14. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014; 35(41):2873.
  15. Ferreira TDA, Chagas ISS, Ramos RTT, et al. Congenital thoracic malformations in pediatric patients: two decades of experience. J Bras Pneumol. 2015; 41(2): 196-199.
  16. Friedman T, Quencer KB, Kishore SA, et al. Malignant Venous Obstruction: Superior Vena Cava Syndrome and Beyond. Semin Intervent Radiol. 2017; 34(4):398.
  17. Hannuksela M, Stattin E, Johansson B, et al. Screening for Familial Thoracic Aortic Aneurysms with Aortic Imaging Does Not Detect All Potential Carriers of the Disease. Aorta (Stamford). 2015; 3(1): 1–8.
  18. Hellinger JC, Daubert M, Lee EY, et al. Congenital thoracic vascular anomalies: Evaluation with state-of-the-art MR imaging and MDCT. Radiol Clin N Am. 2011; 49:969-996.
  19. Hiratzka LF, Bakris GL, Beckman JA , et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010; 121(13):e266.
  20. Karaosmanoglu AD, Khawaja RD, Onur MR, et al. CT and MRI of aortic coarctation: Pre- and postsurgical findings. AJR Am J Roentgenol. 2015; 204(3):W224-33.
  21. Keser G, Direskeneli H, Aksu K. Management of Takayasu arteritis: a systematic review. Rheumatology. 2014; 53(5):793–801.
  22. Kirsch J, Brown RKJ, Henry TS, et al. ACR Appropriateness Criteria® Acute Chest Pain-Suspected Pulmonary Embolism. JACR. 2017; 14(Suppl 5):S2-S12.
  23. Kolandaivelu A. Role of Cardiac Imaging (CT/MR) Before and After RF Catheter Ablation in Patients with Atrial Fibrillation. J Atr Fibrillation. 2012; 5(2): 523.
  24. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). European Heart Journal. 2014; 35(43):3033–3080.
  25. Lawrence PF, Gloviczki P. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. Journal of Vascular Surgery. 2018;68(1):1. doi:10.1016/j.jvs.2018.05.012.
  26. Li J, Feng L, Li J, et al. Diagnostic accuracy of magnetic resonance angiography for acute pulmonary embolism: A systematic review and meta-analysis. Vasa. 2016; 45:149-154.
  27. Long Q, Zha Y, Yang Z. Evaluation of pulmonary sequestration with multidetector computed tomography angiography in a select cohort of patients: A retrospective study. Clinics (Sao Paul). 2016; 71(7): 392–398.
  28. Lopez-Costa I, Bhalla S, Raptis C. Magnetic resonance imaging for pulmonary hypertension: methods, applications, and outcomes. Top Magn Reson Imaging. 2014; 23(1):43-50.
  29. Osiro S, Zurada A, Gielecki J, et, al. A review of subclavian steal syndrome with clinical correlation. Med Sci Monit. 2012; 18(5): RA57-RA63.
  30. Pascall E, Tulloh RMR. Pulmonary hypertension in congenital heart disease. Future Cardiol. 2018; 14(4): 343–353.
  31. Poletto E, Mallon MG, Stevens RM, et al. Imaging review of aortic vascular rings and pulmonary sling. J Am Osteopath Coll Radiol. 2017; 6(2):5-14.
  32. Potter BJ, Pinto DS. Subclavian Steal Syndrome. Circulation. 2014; 129:2320–2323.
  33. Povlsen S, Povlsen B. Diagnosing thoracic outlet syndrome: Current approaches and future directions. Diagnostics (Basel). 2018; 8(1):21.
  34. Rose-Jones, LJ, Mclaughlin VV. Pulmonary hypertension: Types and treatments. Curr Cardiol Rev. 2015 Feb; 11(1):73-79.
  35. Sancak T, Cangir AK, Atasoy C, Ozdemir N. The role of contrast enhanced three-dimensional MR angiography in pulmonary sequestration. Interact Cardiovasc Thorac Surg. 2003;2(4):480-482. doi:10.1016/S1569-9293(03)00118-X.
  36. Schiebler ML, Nagle SK, Francois CJ, et al. Effectiveness of MR angiography for the primary diagnosis of acute pulmonary embolism: Clinical outcomes at 3 months and 1 year. J Magn Reson Imaging. 2013; 38:914-925.
  37. Singh B, Mommer SK, Erwin PJ, et al. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism--revisited: A systematic review and meta-analysis. Emerg Med J. 2013;30(9):701-6.
  38. Swift AJ, Rajaram S, Condliffe R, et al. Diagnostic accuracy of cardiovascular magnetic resonance imaging of right ventricular morphology and function in the assessment of suspected pulmonary hypertension results from the ASPIRE registry. J Cardiovasc Magn Reson. 2012; 14:40.
  39. Uthof H, Pena C, Katzen BT, et al. Current clinical practice in postoperative endovascular aneurysm repair imaging surveillance. J Vascular and interventional Radiology. 2012; 23(9): 1152–1159.
  40. Verma S, Siu SC. Aortic dilatation in patients with bicuspid aortic valve. N Engl J Med. 2014;370(20):1920-1929. doi:10.1056/NEJMra1207059.
  41. Zucker EJ, Gnguli S, Ghoshhajra BB, et al. Imaging of venous compression syndromes. Cardiovasc Diagn Ther. 2016; 6:519-532.    

Coding Section 

Codes Number Description
CPT 71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)

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 non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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

History From 2013 Forward     

11/03/2021 

Annual reivew adding verbiage regarding follow up for bicuspid aortic valve, suspected vascular cause of dysphagia or expiratory wheezing, indications for follow up and combination studies. Adding pulmonary embolism criteria. Also updating description and references. 

11/02/2020 

Annual review, policy reorganized for clarity, updating references. 

11/13/2019 

Interim review. Reformatting policy for clarity and specificity 

11/07/2019 

Annual review, updating references, no change to policy intent. 

11/06/2019 

Annual review, updating references, no change to policy intent. 

11/14/2018 

Annual review, adding medical necessity criteria fo r pulmonary sequestration, central venous thrombosis and thoracic outlet syndrome. 

11/01/2017 

Annual review, policy verbiage being reformatted for clarity and specificity. No other changes made. 

11/01/2016

Annual review, no change to policy intent. 

10/29/2015 

Annual review, no change to policy intent. 

11/10/2014 

Annual review, no change to policy intent. Added coding. 

11/01/2013

No changes in policies.

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