Magnetic Resonance Angiography (MRA)

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6 – Hospital Services Covered Under Part B:

20.4 Outpatient Diagnostic Services.

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services:

80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Part 4:

220.2 Magnetic Resonance Imaging

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 13 – Radiology Services and Other Diagnostic Procedures:

40.1 Magnetic Resonance Angiography

CMS Transmittal No. 7040, Publication 100-03, Medicare National Coverage Determinations (NCD)Manual, Change Request #7040, July 9, 2010, Magnetic Resonance Angiography (MRA).

CMS Transmittal No. 2045, Publication 100-04, Medicare Claims Processing Manual, Change Request #7147, September 10, 2010, October 2010 Update of the Ambulatory Surgical Center (ASC) Payment System.

CMS Transmittal No. 2050, Publication 100-04, Medicare Claims Processing Manual, Change Request #7117, September 17, 2010, October 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS).

CMS Transmittal No. 2051, Publication 100-04, Medicare Claims Processing Manual, Change Request #7112, September 17, 2010, October Update to the 2010 Medicare Physician Fee Schedule Database (MPFSDB).

National Coverage Analysis (NCA); Magnetic Resonance Angiography of the Abdomen and Pelvis (CAG-00142N). http://www.cms.hhs.gov/ncdr/memo.asp?id=51. Accessed June 4, 2003.

National Coverage Determination. Magnetic Resonance Angiography. Publication 6. http://www.cms.hhs.gov/ncd/searchdisplay.asp?NCD_ID=178&NCD_vrsn_num=2. Accessed June 4, 2003.

Indications:

Please refer to Article A56747, Billing and Coding: Magnetic Resonance Angiography, for national coverage provisions.

Head and Neck
All of the following criteria must apply in order for Medicare to provide coverage for MRA of the head and neck:

• MRA is used to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior cerebral arteries, the vertebral or basilar arteries or the venous sinuses;
  
  
• MRA is performed on patients with conditions of the head and neck for which surgery is anticipated and may be found to be appropriate based on the MRA. These conditions include, but are not limited to, tumor, aneurysms, vascular malformations, vascular occlusion or thrombosis. Within this broad category of disorders, medical necessity is the underlying determinant of the need for an MRA in specific diseases. The medical records should clearly justify and demonstrate the existence of medical necessity; and,
  
  
• MRA and CA are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. Only one of these tests will be covered routinely unless the physician can demonstrate the medical need to perform both tests.

MRA is appropriately used to verify the presence of a condition, suspected because of findings from another test (usually an imaging study). For example, a patient who presents with a transient ischemic attack (TIA) should not undergo MRA simply because he might have a lesion which is amenable to surgery. However, if that patient has a carotid bruit and is found by Doppler study to have carotid stenosis, an MRA may be appropriate to evaluate the stenotic section of artery for surgical intervention. Please note that the anticipated surgery may be a percutaneous procedure such as carotid angioplasty with stent insertion.

Another patient may present with a headache; it is not appropriate to proceed directly to MRA to rule out the possibility of an intracranial aneurysm. However, if that patient was found to have a clinically significant amount of blood in the cerebrospinal fluid, or the patient demonstrated signs and symptoms strongly suggesting an unruptured intracranial aneurysm, an MRA (or cerebral angiogram) may be appropriate. An MRA is not considered medically necessary for screening asymptomatic patients for intracranial aneurysms.

Please note that the anticipated surgery may be a percutaneous procedure such as carotid angioplasty with stent insertion.

Peripheral Arteries of Lower Extremities

• Both MRA and CA may be useful in some cases, such as:
  A patient has had CA and this test was unable to identify a viable run-off vessel for bypass. When exploratory surgery is not believed to be a reasonable medical course of action for this patient, MRA may be performed to identify the viable runoff vessel; or,
• A patient has had MRA, but the results are inconclusive.

Abdomen and Pelvis

An MRA of the abdomen for evaluation of possible renal artery stenosis would not be considered medically necessary without some evidence consistent with renovascular hypertension. Such evidence might include:

• a history of early or late onset of hypertension, hypertension refractory to medication, or worsening renal function;
• the presence of a renal artery bruit;
• laboratory tests (elevated serum renins, increasing creatinine); or
• other radiologic tests (ultrasound, captopril scintigraphy, or other imaging showing small kidney or unequal kidney sizes).

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This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

American College of Radiology Expert Panel on Cardiovascular Imaging. Acute Chest Pain, Blunt Trauma, sudden Onset of Cold, Painful Leg, Recurrent Symptoms Following Lower Extremity Angioplasty, Recurrent Symptoms Following Lower Extremity Bypass Surgery. ACR Appropriateness Criteria 1996; Vol 1&2: CV-1.l-CV-1.7, CV-3.1-CV-3.7, CV-6.1-CV-6.7, CV2-1, 1-CV2-1.8, CV2-7, 1-CV2-7.6, CV2-8.8, CV2-9.1-CV2-9-10.

American College of Radiology Expert Panel on Neuro Imaging. Asymptomatic Cerebrovascular Disease. ACR Appropriateness Criteria 1996; Vol 1&2:NI-1.25.

American College of Radiology. Vascular/MRA. Techniques and indications [ACR standard for MRI]. http://acr.org/departments/stan-accred/standards/pdf-standards/mri/monograph-vasc.pdf. Accessed June 15, 1999.

Cambria RP, Kaufman JA, L’Italien GJ, et al. Magnetic resonance angiography in the management of lower extremity arterial occlusive disease: a prospective study. J Vasc Surg. 1997;25:380-389.

Fattori R, Celleti F, Descovich B, et al. Evolution of post-traumatic aortic aneurysm in the subacute phase: magnetic resonance imaging follow up as a support of the surgical timing. Eur J Cardiothorac Surg. 1998;13:582-587.

Other Medicare contractors.

Postma CT, Joosten FB, Rosenbusch G, Thien T. Magnetic resonance angiography has a high reliability in the detection of renal artery stenosis. Am J Hypertens. 1997;10:957-963.

Remonda L, Heid O, Schroth G. Carotid artery stenosis, occlusion, and pseudo-occlusion: first-pass, gadolinium-enhanced, three-dimensional MR angiography – preliminary study. Radiology. 1998;209(1):95-102. 

Source added from reconsideration request April 2018.

Thompson BG, Brown RD, Jr., Amin-Hanjani S, et al. Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46(8):2368-2400.

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• MRA