PROPOSED Local Coverage Determination (LCD)

Magnetic Resonance Angiography

DL34424

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

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Contractor Information

Proposed LCD Information

Document Information

Source LCD ID
L34424
Proposed LCD ID
DL34424
Original ICD-9 LCD ID
Not Applicable
Proposed LCD Title
Magnetic Resonance Angiography
Proposed LCD in Comment Period
Source Proposed LCD
Original Effective Date
N/A
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
ANTICIPATED 10/29/2025
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(1)(E) excludes expenses for items or services which are not reasonable and necessary to carry out research conducted pursuant to §1142 of the Act.

Title XVIII of the Social Security Act, §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical checkups.

42 CFR §410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §20 Services Not Reasonable and Necessary

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220.2 Magnetic Resonance Imaging (MRI).

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Magnetic resonance angiography (MRA) is a modern diagnostic technique based on the effect of nuclear magnetic resonance and is like magnetic resonance imaging (MRI). During the procedure, the device reads electromagnetic waves received during the oscillation of the nuclei of hydrogen atoms, after which the computer converts the information received into a three-dimensional image of the zone under study. MRA is utilized to carry out studies of arteries, veins and lymphatic vessels of any location, to carry out a detailed assessment of the state of vascular networks, to identify pathological changes in the early stages, and to determine the cause of the pathology.1

The coverage criteria and definition of MRA are found in the CMS Internet-only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220.2. MRA with or without contrast is considered appropriate when it can replace a more invasive test (e.g., contrast angiography) and reduce risk for beneficiaries. MRA is a covered indication for various diseases and abnormalities involving the arterial, venous and lymphatic systems. In addition, the services must be reasonable and necessary for the diagnosis or treatment of the specific patient involved.

The use of MRA would have the same contraindications as MRI and should not be used in patients with implanted ferromagnetic structures and electronic devices.

Summary of Evidence

MRA encompasses several imaging techniques based on MRI developed for studying the arterial and venous systems. The benefits of an MRA in comparison to traditional angiography is that it is noninvasive, it lacks ionizing radiation exposure, it has the potential for a non-contrast examination, and it can produce high-resolution volumetric images. The MRA gadolinium contrast material is less likely to cause an allergic reaction than the iodine-based contrast materials used for computed tomography scanning.

An MRA is often indicated to evaluate the following abnormalities and conditions and is used for screening1 and monitoring purposes1: arterial aneurysm(s)1, arteriovenous malformations2-4, aortic coarctation1, aortic dissection5,6, cerebral stroke1, carotid artery disease7,8, peripheral atherosclerosis of the extremities1, congenital heart disease1, coronary artery disease and, if indicated, graft patency9-12, mesentery artery ischemia13,14, renal artery stenosis15, pulmonary embolism16,17, trigeminal neuralgia18-20, moyamoya disease21,22 and intracranial aneurysms.23,24

MRA has the same contraindications as MRI, including patients with implanted ferromagnetic structures and electronic devices. Such devices might include, but are not limited to the following: a cardiac implantable electronic device, mechanical metallic heart valves, metallic foreign bodies, implantable neurostimulation system, cochlear implants/ear implant, non-removable drug infusion pumps, catheters with metallic components, cerebral artery aneurysm clips which are non-MRI compatible, and tissue expanders with magnetic infusion ports.25 Other contraindications for use of the contrast medium include a previous allergic or anaphylactic reaction to gadolinium.26

Analysis of Evidence (Rationale for Determination)

MRA of cerebral vessels is useful to create detailed three-dimensional images of vascular networks and surrounding brain tissues, identify hematomas, hemorrhages, aneurysms, arteriovenous shunts and areas of circulatory disorders. MRI angiography is indicated for suspected post-traumatic intracranial hematoma, stroke, chronic cerebral ischemia with vertebrobasilar insufficiency, encephalopathy, post-traumatic or post-stroke changes, as well as with vegetative-vascular dystonia, pituitary adenoma, Parkinson’s disease and some other pathological conditions. The study can be both with and without contrast.

MRA of the vessels of the extremities is utilized to determine the structure of vascular networks, the condition, localization and interposition of the arteries and veins of the extremities, as well as hemodynamic parameters in unchanged areas and areas of pathological changes. MRA is used for atherosclerosis, vasculitis, thrombosis, chronic venous insufficiency, angiopathies of various genesis, traumatic injuries of arteries and veins, compression or germination of vessels by neoplasms, aneurysms, malformations and vascular dysplasia of the extremities. In some cases, contrast-free MRA is performed. When indicated, gadolinium contrast is used.

MRA of mesenteric vessels is performed to recreate a complete picture of the localization and structure of the abdominal aorta and the vessels departing from it and to identify various pathological changes (structural abnormalities, stenosis, occlusion, traumatic injury, etc.). MRA is prescribed for circulatory disorders in the abdominal aorta basin, with suspicion of abdominal aorta coarctation, atherosclerotic lesion of abdominal vessels, aneurysm aorta, malformations and vascular ruptures of traumatic origin. Vascular contrast can be used to increase the informative value of MRA.

MRA of the lymphatic system makes it possible to assess the condition of the entire lymphatic system and its individual areas. During the procedure, lymph nodes and large collectors are examined. A determination of the level of fluid content in tissues can be made and conclusions about the degree of disruption of lymphatic drainage function can be ascertained. MRA is used for lymphedema caused by inflammatory processes, oncological lesions and fibrous changes that have arisen as a result of previously treated and untreated diseases.27

In addition, when utilized to make a diagnosis, MRA of the spinal vessels, MRA of the heart and coronary vessels, MRA of the thoracic aorta and several other studies may also be indicated.

Based upon the evidence reviewed, there may be other indications for MRA due to its utility to detect abnormalities involving the blood vessels and lymphatic system. Therefore, MRA is considered reasonable and necessary with and without contrast agent to assess any of the above indications and can be used for other vascular abnormalities when clinical indications are reasonable and necessary.

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
The LCD is being presented for comment to expand coverage to Medicare Part B, in addition to Medicare Part A. There are no limitations in coverage since the coverage has been expanded to include the lymphatic system. Codes I88.0, I88.1, I88.8, I89.0, I89.1, I89.8, L03.121, L03.122, L03.123, L03.124, L03.125, L03.126, L03.212, L03.222, L03.321, L03.322, L03.323, L03.324, L03.325, L03.326, L03.327, L03.891, L03.898, L04.0, L04.1, L04.2, L04.3, L04.8, and Q82.0 were added to the related draft Billing and Coding article under Group 7 ICD-10-CM codes. Comments are only being accepted regarding the addition of Part B services and this expansion of coverage. Coverage Indications, Limitations and/or Medical Necessity
ICD-10 Codes that Support Medical Necessity
Associated Information

Utilization Guidelines

Medicare will allow coverage of MRIs for patients with implanted permanent pacemakers when used according to the Food and Drug Administration's (FDA) approved labeling for use in an MRI environment.

Sources of Information
N/A
Bibliography
  1. Lim RP, Koktzoglou I. Noncontrast magnetic resonance angiography: Concepts and clinical applications. Radiol Clin North Am. 2015;53(3):457-476.
  2. Arai N, Akiyama T, Fujiwara K, et al. Silent MRA: Arterial spin labeling magnetic resonant angiography with ultra-short time echo assessing cerebral arteriovenous malformation. Neuroradiology. 2020;62(4):455-461.
  3. Brunozzi D, Hussein AE, Shakur SF, et al. Contrast time-density time on digital subtraction angiography correlates with cerebral arteriovenous malformation flow measured by quantitative magnetic resonance angiography, angioarchitecture, and hemorrhage. Neurosurgery. 2018;83(2):210-216.
  4. Cheng YC, Chen HC, Wu CH,et al. Magnetic resonance angiography in the diagnosis of cerebral arteriovenous malformation and dural arteriovenous fistulas: Comparison of time-resolved magnetic resonance angiography and three dimensional time-of-flight magnetic resonance angiography. Iran J Radiol. 2016;13(2):e19814.
  5. Baliga RR, Nienaber CA, Bossone E, et al. The role of imaging in aortic dissection and related syndromes. JACC Cardiovasc Imaging. 2014;7(4):406-424.
  6. Kinner S, Eggebrecht H, Maderwald S, et al. Dynamic MR angiography in acute aortic dissection. J Magn Reson Imaging. 2015;42(2):505-514.
  7. Fellner C, Lang W, Janka R, Wutke R, Bautz W, Fellner FA. Magnetic resonance angiography of the carotid arteries using three different techniques: Accuracy compared with intraarterial x-ray angiography and endarterectomy specimens. J Magn eason Imaging. 2005;21(4):424-431.
  8. Saxena A, Ng EY, Lim ST. Imaging modalities to diagnose carotid artery stenosis: Progress and prospect. Biomed Eng Online. 2019;18(1):66.
  9. Hajhosseiny R, Bustin A, Munoz C, et al. Coronary magnetic resonance angiography: Technical innovations leading us to the promised land? JACC Cardiovasc Imaging. 2020;13(12):2653-2672.
  10. Dai JW, Cao J, Lin L, Li X, Wang YN, Jin ZY. [Feasibility of non-contrast-enhanced coronary magnetic resonance angiography at 3.0T]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2020;42(2):216-221.
  11. Henningsson M, Shome J, Bratis K, Vieira MS, Nagel E, Botnar RM. Diagnostic performance of image navigated coronary CMR angiography in patients with coronary artery disease. J Cardiovasc Magn Reson. 2017;19(1):68.
  12. Kato Y, Ambale-Venkatesh B, Kassai Y, et al. Non-contrast coronary magnetic resonance angiography: Current frontiers and future horizons. MAGMA. 2020;33(5):591-612.
  13. van Dijk LJ, van Petersen AS, Moelker A. Vascular imaging of the mesenteric vasculature. Best Pract Res Clin Gastroenterol. 2017;31(1):3-14.
  14. Hagspiel KD, Flors L, Hanley M, Norton PT. Computed tomography angiography and magnetic resonance angiography imaging of the mesenteric vasculature. Tech Vasc Interv Radiol. 2015;18(1):2-13.
  15. Guo X, Gong Y, Wu Z, Yan F, Ding X, Xu X. Renal artery assessment with non-enhanced MR angiography versus digital subtraction angiography: Comparison between 1.5 and 3.0 T. Eur Radiol. 2020;30(3):1747-1754.
  16. Pressacco J, Papas K, Lambert J, et al. Magnetic resonance angiography imaging of pulmonary embolism using agents with blood pool properties as an alternative to computed tomography to avoid radiation exposure. Eur J Radiol. 2019;113:165-173.
  17. Ley S, Kauczor HU. MR imaging/magnetic resonance angiography of the pulmonary arteries and pulmonary thromboembolic disease. Magn Reson Imaging Clin N Am. 2008;16(2):263-273.
  18. Hao YB, Zhang WJ, Chen MJ, Chai Y, Zhang WH, Wei WB. Sensitivity of magnetic resonance tomographic angiography for detecting the degree of neurovascular compression in trigeminal neuralgia. Neurol Sci. 2020;41(10):2947-2951.
  19. Gamaleldin OA, Donia MM, Elsebaie NA, Abdelrazek AA, Rayan T, Khalifa MH. Role of fused three-dimensional time-of-flight magnetic resonance angiography and 3-dimensional T2-weighted imaging sequences in neurovascular compression. World Neurosurg. 2020;133:e180-e186.
  20. Docampo J, Gonzalez N, Muñoz A, Bravo F, Sarroca D, Morales C. Neurovascular study of the trigeminal nerve at 3t MRI. Neuroradiol J. 2015;28(1):28-35.
  21. Savolainen M, Pekkola J, Mustanoja S, et al. Moyamoya angiopathy: Radiological follow-up findings in Finnish patients. J Neurol. 2020;267(8):2301-2306.
  22. Lehman VT, Cogswell PM, Rinaldo L, et al. Contemporary and emerging magnetic resonance imaging methods for evaluation of moyamoya disease. Neurosurg Focus. 2019;47(6):E6.
  23. Malhotra A, Wu X, Matouk CC, Forman HP, Gandhi D, Sanelli P. MR angiography screening and surveillance for intracranial aneurysms in autosomal dominant polycystic kidney disease: A cost-effectiveness analysis. Radiology. 2019;291(2):400-408.
  24. Nielsen R, Hauerberg J, Munthe S, et al. [Screening for intracranial aneurysms]. Ugeskr Laeger. 2019;181(2).
  25. De Leucio A, De Jesus O. MR Angiogram. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024..
  26. Mallio CA, Rovira À, Parizel PM, Quattrocchi CC. Exposure to gadolinium and neurotoxicity: Current status of preclinical and clinical studies. Neuroradiology. 2020;62(8):925-934.
  27. Pamarthi V, Pabon-Ramos WM, Marnell V, Hurwitz LM. MRI of the central lymphatic system: Indications, imaging technique, and pre-procedural planning. Top Magn Reson Imaging. 2017;26(4):175-180.
Open Meetings
Meeting Date Meeting States Meeting Information
10/07/2024 Alabama
Georgia
North Carolina
South Carolina
Tennessee
Virginia
West Virginia

Web Conference

N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
08/29/2024
Comment Period Start Date
08/29/2024
Comment Period End Date
10/12/2024
Reason for Proposed LCD
  • Provider Education/Guidance
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD
Part A Policy
PO Box 100238 (JM) or PO Box 100305 (JJ)
AG-275
Columbia, SC 29202
A.Policy@PalmettoGBA.com

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Utilization Guidelines

Medicare will allow coverage of MRIs for patients with implanted permanent pacemakers when used according to the Food and Drug Administration's (FDA) approved labeling for use in an MRI environment.

Sources of Information
N/A
Bibliography
  1. Lim RP, Koktzoglou I. Noncontrast magnetic resonance angiography: Concepts and clinical applications. Radiol Clin North Am. 2015;53(3):457-476.
  2. Arai N, Akiyama T, Fujiwara K, et al. Silent MRA: Arterial spin labeling magnetic resonant angiography with ultra-short time echo assessing cerebral arteriovenous malformation. Neuroradiology. 2020;62(4):455-461.
  3. Brunozzi D, Hussein AE, Shakur SF, et al. Contrast time-density time on digital subtraction angiography correlates with cerebral arteriovenous malformation flow measured by quantitative magnetic resonance angiography, angioarchitecture, and hemorrhage. Neurosurgery. 2018;83(2):210-216.
  4. Cheng YC, Chen HC, Wu CH,et al. Magnetic resonance angiography in the diagnosis of cerebral arteriovenous malformation and dural arteriovenous fistulas: Comparison of time-resolved magnetic resonance angiography and three dimensional time-of-flight magnetic resonance angiography. Iran J Radiol. 2016;13(2):e19814.
  5. Baliga RR, Nienaber CA, Bossone E, et al. The role of imaging in aortic dissection and related syndromes. JACC Cardiovasc Imaging. 2014;7(4):406-424.
  6. Kinner S, Eggebrecht H, Maderwald S, et al. Dynamic MR angiography in acute aortic dissection. J Magn Reson Imaging. 2015;42(2):505-514.
  7. Fellner C, Lang W, Janka R, Wutke R, Bautz W, Fellner FA. Magnetic resonance angiography of the carotid arteries using three different techniques: Accuracy compared with intraarterial x-ray angiography and endarterectomy specimens. J Magn eason Imaging. 2005;21(4):424-431.
  8. Saxena A, Ng EY, Lim ST. Imaging modalities to diagnose carotid artery stenosis: Progress and prospect. Biomed Eng Online. 2019;18(1):66.
  9. Hajhosseiny R, Bustin A, Munoz C, et al. Coronary magnetic resonance angiography: Technical innovations leading us to the promised land? JACC Cardiovasc Imaging. 2020;13(12):2653-2672.
  10. Dai JW, Cao J, Lin L, Li X, Wang YN, Jin ZY. [Feasibility of non-contrast-enhanced coronary magnetic resonance angiography at 3.0T]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2020;42(2):216-221.
  11. Henningsson M, Shome J, Bratis K, Vieira MS, Nagel E, Botnar RM. Diagnostic performance of image navigated coronary CMR angiography in patients with coronary artery disease. J Cardiovasc Magn Reson. 2017;19(1):68.
  12. Kato Y, Ambale-Venkatesh B, Kassai Y, et al. Non-contrast coronary magnetic resonance angiography: Current frontiers and future horizons. MAGMA. 2020;33(5):591-612.
  13. van Dijk LJ, van Petersen AS, Moelker A. Vascular imaging of the mesenteric vasculature. Best Pract Res Clin Gastroenterol. 2017;31(1):3-14.
  14. Hagspiel KD, Flors L, Hanley M, Norton PT. Computed tomography angiography and magnetic resonance angiography imaging of the mesenteric vasculature. Tech Vasc Interv Radiol. 2015;18(1):2-13.
  15. Guo X, Gong Y, Wu Z, Yan F, Ding X, Xu X. Renal artery assessment with non-enhanced MR angiography versus digital subtraction angiography: Comparison between 1.5 and 3.0 T. Eur Radiol. 2020;30(3):1747-1754.
  16. Pressacco J, Papas K, Lambert J, et al. Magnetic resonance angiography imaging of pulmonary embolism using agents with blood pool properties as an alternative to computed tomography to avoid radiation exposure. Eur J Radiol. 2019;113:165-173.
  17. Ley S, Kauczor HU. MR imaging/magnetic resonance angiography of the pulmonary arteries and pulmonary thromboembolic disease. Magn Reson Imaging Clin N Am. 2008;16(2):263-273.
  18. Hao YB, Zhang WJ, Chen MJ, Chai Y, Zhang WH, Wei WB. Sensitivity of magnetic resonance tomographic angiography for detecting the degree of neurovascular compression in trigeminal neuralgia. Neurol Sci. 2020;41(10):2947-2951.
  19. Gamaleldin OA, Donia MM, Elsebaie NA, Abdelrazek AA, Rayan T, Khalifa MH. Role of fused three-dimensional time-of-flight magnetic resonance angiography and 3-dimensional T2-weighted imaging sequences in neurovascular compression. World Neurosurg. 2020;133:e180-e186.
  20. Docampo J, Gonzalez N, Muñoz A, Bravo F, Sarroca D, Morales C. Neurovascular study of the trigeminal nerve at 3t MRI. Neuroradiol J. 2015;28(1):28-35.
  21. Savolainen M, Pekkola J, Mustanoja S, et al. Moyamoya angiopathy: Radiological follow-up findings in Finnish patients. J Neurol. 2020;267(8):2301-2306.
  22. Lehman VT, Cogswell PM, Rinaldo L, et al. Contemporary and emerging magnetic resonance imaging methods for evaluation of moyamoya disease. Neurosurg Focus. 2019;47(6):E6.
  23. Malhotra A, Wu X, Matouk CC, Forman HP, Gandhi D, Sanelli P. MR angiography screening and surveillance for intracranial aneurysms in autosomal dominant polycystic kidney disease: A cost-effectiveness analysis. Radiology. 2019;291(2):400-408.
  24. Nielsen R, Hauerberg J, Munthe S, et al. [Screening for intracranial aneurysms]. Ugeskr Laeger. 2019;181(2).
  25. De Leucio A, De Jesus O. MR Angiogram. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024..
  26. Mallio CA, Rovira À, Parizel PM, Quattrocchi CC. Exposure to gadolinium and neurotoxicity: Current status of preclinical and clinical studies. Neuroradiology. 2020;62(8):925-934.
  27. Pamarthi V, Pabon-Ramos WM, Marnell V, Hurwitz LM. MRI of the central lymphatic system: Indications, imaging technique, and pre-procedural planning. Top Magn Reson Imaging. 2017;26(4):175-180.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
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Public Versions
Updated On Effective Dates Status
08/23/2024 N/A - N/A Superseded You are here

Keywords

  • MRA
  • Magnetic Resonance Angiography

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