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MP 6.01.16 (Archived) Magnetic Resonance Angiography of Vessels of the Head, Neck, Abdomen, Pelvis, and Lower Extremity

Medical Policy
Section
Radiology
 
Original Policy Date
7/31/97
Last Review Status/Date
local policy (archived)/2:2011
Issue
4:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Magnetic resonance angiography (MRA) is a technique for imaging vascular anatomy and pathology that does not use ionizing radiation. MRA is performed using magnetic resonance imaging (MRI) machines, and vascular images may be generated either with or without intravenous contrast agents, depending on the clinical application. However, the contrast agents used for MRA are associated with less risk of allergic reaction or nephrotoxicity than those used for conventional angiography. MRA is the general term used to describe MR imaging of vascular structures, but when MR is used to image a vein instead of an artery, the term “magnetic resonance venography” (MRV) may be used. The technical capabilities of current MRA make it most suitable for evaluation of medium-to-large size vessels. In the head, this includes the Circle of Willis and major posterior circulation vessels, while in the body this includes the aorta and its major arterial branches such as carotid, renal, hepatic and mesenteric arteries. MRA is less suitable for providing detailed information about the small, peripheral vasculature.


Policy

MRA of the head may be considered medically necessary for the assessment of:

  • aneurysm
  • Arterial thromboembolic disease
  • Arteriovenous malformation (AVM)
  • Congenital Anomalies of the Cerebral Circulation
  • Dissection
  • Dural Arteriovenous Fistula (DAVF)
  • Endovascular Neuro-interventional Procedure for Intra-cranial aneurysm, Arteriovenous Malformation (AVM) and Dural Arteriovenous Fistula (DAVF): for post-treatment evaluation
  • Headache: worst headache of life; exertional headache, positional headache
  • Intra-cranial hemorrhage
  • Intramural hematoma
  • Pre-procedure for Neurosurgical Operative or Percutaneous Vascular interventions
  • Pulsatile tinnitus, for vascular etiology
  • Recent cerebrovascular accident
  • Stenosis or occlusion of carotid and cerebral arteries - suspected or confirmed
  • Stenosis or occlusion of vertebral and basilar arteries
  • Traumatic vascular injury
  • Vascular abnormalities associated with sickle cell disease in children
  • Vascualr supply to tumors
  • Vasculitis
  • Venous thrombosis (including dural venous sinus thrombosis) or venous compression

MRA of the neck may be considered medically necessary for the assessment of:

  • Aneurysm
  • Arterial Thromboembolism
  • Arteriovenous malformation
  • Congenital Anomalies of the carotid and vertebrobasilar circulations
  • Disecction
  • Intramural Hematoma
  • Post-operative evaluation, following carotid endarterectomy
  • Pre-operative vascular delineation of blood supply to tumors, such as carotid body (Glomus) tumors
  • Stenosis or occlusion of the Extracranial carotid arteries
  • Stenosis or occlusion of the vertebral arteries
  • Traumatic vascular injury to the extracranial carotid and vertebral arteries
  • Vasculopathy, including fibromuscular dysplasia (FMD)
  • Venous thrombosis or compression

MRA of the abdomen may be considered medically necessary for the assessment of patients with the following clinical indications:

  • aneurysm - of the abdominal aorta and/or branch vessel 
  • arteriovenous malformation (AVM) or fistula (AVF)
  • Dissection - of the abdominal aorta and/or branch vessel
  • Endovascular stent graft placement for abdominal aortic aneurysm repair 
  • Intramural hematoma - of the abdominal aorta and/or branch vessel
  • Mesenteric ischemia - suspected or known
  • Portal hypertension
  • Pseudoaneurysm - of the abdominal aorta and/or branch vessel
  • Renal artery stenosis
  • Stenosis or occlusion of the abdominal aorta or branch vessels
  • Suspected leak following abdominal aortic surgery
  • Traumatic vascular injury
  • Vascular anatomic delineation for other surgical and interventional procedures
  • Vascular evaluation of lower extremity claudication
  • Vascular invasion or compression by an abdominal tumor
  • Vasculitis
  • Venous thrombosis or occlusion

 

MRA of the pelvis may be considered medically necessary for the assessment of patients with the following clinical indications:

  • Aneurysm
  • Arteriovenous malformation (AVM) or fistula (AVF)
  • Dissection - of the lower abdominal aorta and/or branch vessel
  • Endovascular stent graft placement for abdominal aortic aneurysm repair 
  • Intramural hematoma - of the lower abdominal aorta and/or branch vessel
  • Mesenteric ischemia - suspected or known
  • Pseudoaneurysm - of the lower abdominal aorta and/or branch vessel
  • Stenosis or occlusion of the lower abdominal aorta, iliac arteries or other branch vessels
  • Suspected leak following abdominal aortic surgery
  • Traumatic vascular injury
  • Vascular anatomic delineation for surgical and interventional procedures (other than endovascular stent graft placement)
  • Vascular invasion or compression by a pelvic tumor
  • Venous thrombosis or occlusion

MRA of the upper extremity may be considered medically necessary for the assessment of patients with the following clincal indications:

  • Aneurysm
  • Arterial entrapment syndrome
  • Arteriovenous malformation (AVM) or fistula (AVF)
  • Dialysis graft evaluation
  • Dissection
  • Intramural hematoma
  • Pre- and Post-operative or interventional vascular procedure - for luminal patency versus re-stenosis (due to atherosclerosis, thromboembolism, intimal hyperplasia or other cause) as well as post-procedural complications (such as pseudoaneurysms related to surgical bypass grafts or vascular stents)
  • Raynaud's syndrome
  • Steno-occlusive disease
  • Thromboembolic disease - arterial or venous
  • Vascular invasion or compression by a muskuloskeletal neoplasm
  • Vasculitis

 

MRA of the lower extremity may be considered medically necessary for the assessment of patients with the following clincal indications:

ARTERIAL DISORDERS

  • Aneurysm
  • Arterial entrapment syndrome
  • Critical ischemia
  • Dissection
  • Intramural hematoma
  • Pre-and Post-operative or interventional vascular procedure - for luminal patency versus re-stenosis (due to atherosclerosis, thromboembolism, intimal hyperplasia or other cause) as well as post-procedural complications (such as pseudoaneurysms related to surgical bypass grafts or vascular stents)
  • Pre-operative evaluation for known lower extremity peripheral arterial disease
  • Raynaud's syndrome
  • Vascular assessment for lower extremity claudication
  • Vasculitis

VENOUS DISORDERS

  • Venous thrombosis
  • Venous compression, due to surrounding mass effect

ARTERIAL AND VENOUS DISORDERS

  • Arteriovenous malformation (AVM) or fistula (AVF)
  • Thromboembolic disease - arterial or venous
  • Vascular invasion or compression by a muskuloskeletal neoplasm

 

MRA may be considered medically necessary in the evaluation of potential renal donors for the presence of accessory renal arteries.


Policy Guidelines

Head
 
Invasive cerebral angiography has been traditionally considered the reference standard to which the performance of noninvasive diagnostic tests is compared. Both magnetic resonance angiography (MRA) and transcranial Doppler ultrasonography (TCD) have been shown to be effective noninvasive diagnostic tests for evaluating patients suspected of having intracranial arterial steno-occlusive disease and may be used by some physicians as a replacement for invasive cerebral angiography.

In some circumstances, either MRA or TCD alone may provide adequate information to guide appropriate management; however, there are other circumstances whereby it may be necessary to obtain both noninvasive tests before management decisions can be made. For example, the initial noninvasive study may be technically limited by patient motion (particularly a problem for MRA) or by the patient having an inadequate acoustic window (a problem unique to TCD). When this is the case, diagnostic information may be sought using the alternative noninvasive imaging tool. Furthermore, the results of the initial noninvasive evaluation may be borderline or equivocal. Since CDUS and MRA use different physical and technical principles for evaluating the cerebral vasculature, the information obtained from each test can be complementary rather than duplicative in some circumstances.

Neck
 
Invasive angiography of the cervical carotid arteries has been used traditionally as the definitive preoperative diagnostic evaluation in patients with carotid artery bifurcation stenosis who are being considered for carotid endarterectomy (CEA). However, as recent improvements have been made in noninvasive diagnostic tests to evaluate the carotid bifurcation region, some physicians have favored a preoperative diagnostic approach using noninvasive imaging tests such as carotid duplex ultrasonography (CDUS) and/or MRA to guide management decisions.

CDUS is most commonly used as the initial noninvasive evaluation of the carotid bifurcation as it is less expensive than MRA and generally more readily available than MRA. When the clinical suspicion for steno-occlusive disease is considered along with the results of the initial test (usually CDUS), the physician can decide whether there is sufficient information to determine subsequent management for the patient or whether additional imaging is necessary. One imaging strategy that has emerged and that is supported in the available evidence, uses both CDUS and MRA to evaluate patients prior to CEA. When both noninvasive tests agree as to the necessity of CEA, the surgical management decision is made based on noninvasive imaging alone. However, if there is discordance in the results of MRA and CDUS (e.g., 1 test suggests a severe carotid stenosis but the other test suggests only a mild-to-moderate degree of stenosis), then invasive angiography is performed to determine the management decision. Using this combination strategy, the utilization of invasive angiography for preoperative evaluation for CEA has been reported to decrease substantially.

Abdomen
 
A variety of abdominal vascular conditions have been proposed for evaluation with contrast-enhanced MRA. Patients who are suspected of having renal artery stenosis may benefit when MRA is used to rule out significant stenosis, thus sparing the patient from invasive angiography. Patients with positive results on MRA may require confirmatory angiography before receiving surgical or intravascular stent treatment for renal artery stenosis. However, confirmation may often be performed during the catheterization for the therapeutic procedure. Similarly, patients with suspected chronic mesenteric ischemia or suspected hepatic arterial disease may benefit from the use of MRA. Potential living renal donors may benefit by using contrast-enhanced MRA for preoperative evaluation of renal anatomy as an alternative to invasive digital subtraction angiography and or computed tomographic angiography (CTA), both of which require ionizing radiation and potentially nephrotoxic iodinated intravenous contrast agents.

Patients who are to undergo elective repair of an abdominal aortic aneurysm undergo preoperative angiographic evaluation to delineate the size and location of the aneurysm as well as its relationship with renal and other branch arteries. MRA has been proposed as a replacement for invasive angiography in this situation. Similarly, patients who are to undergo abdominal organ transplantation may require presurgical angiography and may benefit from the use of MRA. CTA is also proposed as a noninvasive alternative, though CT uses iodinated contrast agents that pose a higher risk for allergic and nephrotoxic reactions. Patients with suspected abdominal or pelvic venous thrombo-occlusive disease may benefit by using MRA to obviate the need for invasive venography.

Pelvis
 
Pelvic arteriography or venography may be useful in several situations to avoid the need for invasive angiography. Patients with suspected aorto-iliac atherosclerotic disease may benefit by the use of MRA to avoid the need for invasive angiography, and this evaluation often includes arterial evaluation of the lower extremities as well in patients with suspected peripheral vascular disease (e.g., claudication). Other uses of pelvic MRA would include evaluation of renal arteries with ectopic pelvic location of the kidney and evaluation of pelvic veins for thrombo-occlusive disease.

Lower Extremity
 
MRA may be useful for evaluating the arterial and venous structures of the lower extremity. In patients with suspected peripheral vascular disease, MRA may be able to evaluate the extent of disease and guide therapeutic decision making without the need for invasive angiography. Furthermore, MRA may be more sensitive than conventional angiography in identifying distal runoff vessels in potential candidates for peripheral bypass surgery.


Benefit Application

BlueCard/National Account Issues

No applicable information


Rationale

This Policy is based on a series of TEC Assessments in 1996-1997 (1–3), which focused on MRA of the head, neck, and abdomen. The policy was updated in 2003 with additional information on MRA of the pelvis and lower extremities as a technique to evaluate peripheral vascular disease and MRA of the abdomen for evaluation of potential living renal donors.

MRA of the pelvis and lower extremities has emerged as an important tool for surgical planning, particularly to identify patent distal run-off vessels when surgical revascularization is considered. (4–7) In addition, MRA has been widely used to evaluate the recurrent symptoms in patients who have undergone either angioplasty or surgical revascularization. A meta-analysis of 34 studies conducted by Koelemay et al. (8) found that MRA was accurate foridentifyingstenosis(>50%) or occlusions in the aorto-iliac, femoropopliteal, and infrapopliteal regions. Baum et al. (9) found that MRA is more sensitive for identifying runoff vessels compared with conventional angiography. Use of vessels visible only on MRA for bypass surgery provides an opportunity for limb salvage and when compared with bypass to angiographically visible vessels, graft-patency and limb-salvage outcomes are similar. (10) These roles of MRA are recognized by the American College of Radiology Appropriateness Criteria. (11)

Diagnostic performance of MRA of the abdomen for evaluation of renal anatomy in potential living renal donors has improved with the evolution of contrast-enhanced MRA techniques. Recent studies have shown contrast-enhanced MRA to have good sensitivity and specificity for detection of renal arterial and venous anomalies. Three studies reported sensitivity and specificity of 90% or higher for renal arterial anatomy. (12–14) One study examined the ability of contrast-enhanced MRA to detect arterial, venous, ureteral, or parenchymal anomalies during the presurgical evaluation process for laparoscopic nephrectomy. (15) This study found that preoperative MRA agreed completely with surgical findings in 21 of 28 cases (75%). In this study, the laparoscopic surgical procedure was successful in 27 of 28 cases (96%) and only 1 case required conversion to open nephrectomy, suggesting that some oversights on MRA may not be clinically significant. Furthermore, studies comparing contrast-enhanced MRA to alternatives such as computed tomographic angiography (CTA) and digital subtraction angiography have reported comparable results. (14, 16–18) However, concerns have been raised regarding the ability of MRA or CTA to detect mild or distal-moderate fibromuscular dysplasia (FMD) that can be seen on conventional renal angiography. (19) The prevalence of FMD is about 2% to 6.6% in angiographic case series, and it is unclear what effect donor nephrectomy may have on the subsequent development of hypertension in asymptomatic potential renal donors who have silent FMD. (19)

References:

  1. TEC Assessments 1997: Tab 1
  2. TEC Assessments 1996: Tab 31
  3. TEC Assessments 1996: Tab 32.
  4. Yucel EK, Anderson CM, Edelman RR et al. AHA Scientific Statement. Magnetic resonance angiography: update of applications for extracranial arteries. Circulation 1999; 100(22):2284-301.
  5. Ho VB, Corse WR. MR angiography of the abdominal aorta and peripheral vessels. Radiol Clin North Am 2003; 41(1):115-44.
  6. Rajagopalan S, Prince M. Magnetic resonance angiographic techniques for the diagnosis of arterial disease. Cardiol Clin 2002; 20(4):501-12.
  7. Goyen M, Ruehm SG, Debatin JF. MR angiography for assessment of peripheral vascular disease. Radiol Clin North Am 2002; 40(4):835-46.
  8. Koelemay MJ, Lijmer JG, Stoker J et al. Magnetic resonance angiography for the evaluation of lower extremity arterial disease: a meta-analysis. JAMA 2001; 285(10):1338-45.
  9. Baum RA, Rutter CM, Sunshine JH et al. Multicenter trial to evaluate vascular magnetic resonance angiography of the lower extremity. JAMA 1995; 274(11):875-80.
  10. Carpenter JP, Golden MA, Barker CF et al. The fate of bypass grafts to angiographically occult runoff vessels detected by magnetic resonance angiography. J Vasc Surg 1996; 23(3):483-9.
  11. American College of Radiology Appropriateness Criteria. www.acr.org/dyna/?doc=departments/appropriateness_criteria/toc.html
  12. Fink C, Hallscheidt PJ, Hosch WP et al. Preoperative evaluation of living renal donors: value of contrast-enhanced 3D magnetic resonance angiography and comparison of three rendering algorithms. Eur Radiol 2003; 13(4):794-801.
  13. Jha RC, Korangy SJ, Ascher SM et al. MR angiography and preoperative evaluation for laparoscopic donor nephrectomy. AJR Am J Roentgenol 2002; 178(6):1489-95.
  14. Rankin SC, Jan W, Koffman CG. Noninvasive imaging of living related kidney donors: evaluation with CT angiography and gadolinium-enhanced MR angiography. AJR Am J Roentgenol 2001; 177(2):349-55.
  15. Israel GM, Lee VS, Edye M et al. Comprehensive MR imaging in the preoperative evaluation of living donor candidates for laparoscopic nephrectomy: initial experience. Radiology 2002; 225(2):427-32.
  16. Giessing M, Kroencke TJ, Taupitz M et al. Gadolinium-enhanced three-dimensional magnetic resonance angiography versus conventional digital subtraction angiography: which modality is superior in evaluating living kidney donors? Transplantation 2003; 76(6):1000-2.
  17. Halpern EJ, Mitchell DG, Wechsler RJ et al. Preoperative evaluation of living renal donors: comparison of CT angiography and MR angiography. Radiology 2000; 216(2):434-9.
  18. Hussain SM, Kock MC, IJzermans JN et al. MR imaging: a “one-stop shop” modality for preoperative evaluation of potential living kidney donors. Radiographics 2003; 23(2):505-20.
  19. Andreoni KA, Weeks SM, Gerber DA et al. Incidence of donor renal fibromuscular dysplasia: does it justify routine angiography? Transplantation 2002; 73(7):1112-6.

 

Codes

Number

Description

CPT 

70547, 70548, 70549 

MRA, neck, code range (New 2001 CPT codes) 

 

70544, 70545, 70546 

MRA, head, code range (New 2001 CPT codes) 

 

74185 

Magnetic resonance angiography, abdomen, with or without contrast material 

ICD-9 Procedure 

88.41 

Arteriography of cerebral arteries (includes MRA of head, neck, and spine) 

 

88.47 

Arteriography of intra-abdominal arteries (includes MRA of abdomen) 

ICD-9 Diagnosis 

388.30–388.32 

Tinnitus, code range 

 

430 

Subarachnoid hemorrhage (includes ruptured cerebral aneurysm) 

 

433.0–433.9 

Occlusion and stenosis of precerebral arteries, code range 

 

434.00–434.91 

Occlusion of cerebral arteries, code range (includes thrombosis) 

 

437.0 

Cerebral atherosclerosis 

 

437.3 

Cerebral aneurysm 

 

440.1 

Atherosclerosis of renal artery 

 

441.3–441.9 

Abdominal aneurysm 

 

452 

Portal vein thrombosis 

 

453.0 

Budd-Chiari syndrome (hepatic vein thrombosis) 

 

459.2 

Compression of vein 

 

557 

Vascular insufficiency of intestine 

 

571 

Chronic liver disease and cirrhosis 

 

747.81 

Anomalies of the cerebrovascular system 

 

747.89 

Other specified anomalies of circulatory system (includes congenital aneurysm of specified site not elsewhere classified) 

HCPCS 

C8900. C8901, C8902 

MRA of the abdomen, code range 

 

C8912, C8913, C8914 

MRA of the lower extremity, code range 

 

C8918, C8919, C8920

MRA of the pelvis, code range 

Type of Service 

Radiology 

Place of Service 

Inpatient
 
Outpatient
 


Index

Angiography, Magnetic Resonance (MRA)
Magnetic Resonance Angiography (MRA)
MRA (Magnetic Resonance Angiography)


Policy History

Date Action Reason
07/31/97 Add to Radiology section New policy
10/15/00 Replace policy New CPT code
04/15/02 Replace policy Policy reviewed without literature review; new review date only
12/17/03 Replace policy Policy updated with literature review; policy statements added regarding MRA in pelvis and lower extremity. HCPCS codes added.
10/20/08 Replace policy  policy statement update; added specific criteria for medically necessary indications 
2/2011 policy archived  


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