MRI Chest (Thorax) - CAM 743

Policy 
INDICATIONS FOR CHEST MRI

The combination of superior soft tissue contrast and lack of ionizing radiation may make Chest Magnetic Resonance Imaging (MRI) preferable for the pediatric population or evaluation of the non-lung parenchyma. This must be weighed against a longer acquisition time and greater likelihood of artifact from patient motion. Chest Computed Tomography (CT) is generally better for lung evaluation. 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.

Chest Mass (non-lung parenchymal)
(Azizad, 2016; Carter, 2015, 2016, 2017; Hochhegger, 2011; Mullan, 2011)

  • Mass or lesion, including lymphadenopathy, after non-diagnostic x-ray or ultrasound (Chest CT indicated for pulmonary nodule)
  • Thymoma screening in Myasthenia Gravis patients (Kumar, 2015)
  • Congenital thoracic malformation on other imaging (chest x-ray, echocardiogram, gastrointestinal study, or inconclusive CT) (Ferreira, 2015; Hellinger, 2011; Karaosmanoglu, 2015; Poletto, 2017)

Chest Wall Pain (after initial evaluation with chest x-ray and/or rib series radiographs)

  • History of known or suspected cancer
  • Signs and symptoms of infection (non-lung parenchymal), such as:
    • Accompanying fever
    • Elevated inflammatory markers
    • Known infection at other sites
  • Suspected muscle or tendon tear where imaging would change treatment

Brachial Plexopathy
(Mansukhani, 2013; Vijayasarathi, 2016). 

  • If mechanism of injury or Electromyography/Nerve Conduction Velocity (EMG/NCV) studies are suggestive
  • Chest MRI is preferred study, but neck and/or shoulder (upper extremity) MRI can be ordered depending on the suspected location of injury

Cystic Fibrosis
(Woods, 2020)

  • Can be an alternative to Chest CT to evaluate perfusion abnormalities, bronchiectasis, and mucus plugging if needed for treatment planning

Vascular Diseases are better evaluated with Chest CTA or MRA
(ACR, 2019)

  • 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)
  • Acute or chronic aortic dissection (ACR, 2017; Barman, 2014)
  • Pulmonary hypertension - To evaluate for cause after echocardiogram or right heart catheterization (Ascha 2017, Rose-Jones 2015)

Congenital Malformations

  • Congenital heart disease with pulmonary hypertension (Pascall 2018)
  • Pulmonary sequestration (Sancak, 2003)

Atrial fibrillation with ablation planned
(Kolandaivelu 2012)

Preoperative/procedural evaluation

  • Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation

  • Post-surgical follow-up when records document medical reason requiring additional imaging

Background
Magnetic Resonance Imaging (MRI) is a noninvasive imaging technique for detection and evaluation of various disease and conditions in the chest, e.g., congenital anomalies and aneurysms. MRI may be used instead of computed tomography (CT) in patients with allergies to radiographic contrast or with impaired renal function.

Overview 
MRI and Myasthenia Gravis – Myasthenia Gravis is a chronic autoimmune disease characterized by weakness of the skeletal muscles causing fatigue and exhaustion that is aggravated by activity and relieved by rest. It most often affects the ocular and other cranial muscles and is thought to be caused by the presence of circulating antibodies. Symptoms include ptosis, diplopia, chewing difficulties, and dysphagia. Thymoma has a known association with myasthenia. Contrast-enhanced MRI may be used to identify the presence of a mediastinal mass suggestive of myasthenia gravis in patients with renal failure or allergy to contrast material.

MRI and Thoracic Outlet Syndrome – Thoracic outlet syndrome is a group of disorders involving compression at the superior thoracic outlet that affects the brachial plexus, the subclavian artery, and veins. It refers to neurovascular complaints due to compression of the brachial plexus or the subclavian vessels. Magnetic resonance multi-plane imaging shows bilateral images of the thorax and brachial plexus and can demonstrate the compression of the brachial plexus and venous obstruction.

MRI and Brachial Plexus – MRI is the only diagnostic tool that accurately provides high resolution imaging of the brachial plexus. The brachial plexus is formed by the cervical ventral rami of the lower cervical and upper thoracic nerves which arise from the cervical spinal cord, exit the bony confines of the cervical spine, and traverse along the soft tissues of the neck, upper chest, and course into the arms. 

References 

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Coding Section 

Code Number Description
CPT 71550 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)
  71551 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)
  71552
Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences

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 2019 Forward     

11/08/2021

Annual review, adding criteria related to cystic fibrosis, brachial plexopathy imaging and clarifying the preoperative evaluation criteria. Also updating description and references. 

11/01/2020 

Annual review, adding medical criteria for chest wall pain and other clarifications. Also updating references. 

11/26/2019

New Policy

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