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Date Printed: June 25, 2017: 01:26 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-70540-21

Original Effective Date: 12/15/13

Reviewed 03/26/15

Revised: 04/15/15

Subject: Magnetic Resonance Angiography (MRA) Abdomen and Pelvis

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    

DESCRIPTION:

Magnetic resonance angiography (MRA) is a noninvasive imaging technology, which generates images of the arteries that can be evaluated for evidence of stenosis, occlusion or aneurysms. MRA is used to evaluate the arteries of the abdominal aorta and the renal arteries. A contrast agent (gadolinium) may be used with MRA for better visualization and may be used in individuals who have a history of contrast allergy and who are at high risk of kidney failure.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the magnetic resonance angiography (MRA) of the abdomen and pelvis and imaging results (e.g., images, clinical reports) should be maintained in the member’s medical record. Documentation may be requested as part of the review process.

Magnetic resonance angiography (MRA) of the abdomen and pelvis meets the definition of medical necessity for the following:

Indications for Abdomen MRA:

For evaluation of known or suspected abdominal vascular disease:

Pre-operative evaluation:

Post-operative or post-procedural evaluation:

Indications for Pelvis MRA:

For evaluation of known or suspected pelvic vascular disease:

Pre-operative evaluation:

Post- operative or post-procedural evaluation:

BILLING/CODING INFORMATION:

CPT Coding:

72198

Magnetic resonance angiography, pelvis, with or without contrast material(s)

74185

Magnetic resonance angiography, abdomen, with or without contrast material(s)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

Re-imaging or additional imaging due to poor contrast enhanced exam or technically limited exam is the responsibility of the imaging provider.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for magnetic resonance angiography (MRA) of the abdomen and pelvis.

Documentation Table

LOINC Codes

LOINC

Time Frame

Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology reason for study

18785-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study-date and time

18779-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study observation

18834-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-study observation

18782-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-impression

19005-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology study-recommendation (narrative)

18783-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to the member’s contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products

The following Local Coverage Determination (LCD) was reviewed: Magnetic Resonance Angiography (MRA), (L29218 and L34372) located at fcso.com.

The following National Coverage Determination (NCD) was reviewed: Magnetic Resonance Angiography, (220.3) and Magnetic Resonance Imaging (MRI), (220.2) located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Magnetic Resonance Angiography (MRA) Brain (Head), 04-70540-18
Magnetic Resonance Angiography (MRA) Neck, 04-70540-19

Magnetic Resonance Angiography (MRA) Chest, 04-70540-20

Magnetic Resonance Angiography (MRA) Extremity (Upper and Lower), 04-70540-22

Magnetic Resonance Angiography (MRA) Spinal Canal, 04-70540-23

OTHER:

None applicable.

REFERENCES:

  1. American College of Radiology ACR Appropriateness Criteria®: Radiologic Management of Mesenteric Ischemia, 2011.
  2. ACR-NASCI-SPR Practice Guideline for the Performance of Body Magnetic Resonance Angiography (MRA), 2014.
  3. Desjardins B, Dill KE, Flamm SD et al. ACR Appropriateness Criteria® pulsatile abdominal mass, suspected abdominal aortic aneurysm. International Journal of Cardiovascular Imaging 2013; 29(1): 177-183.
  4. Schwope RB, Alper HJ, Talenfeld AD et al. MR angiography for patient surveillance after endovascular repair of abdominal aortic aneurysms. American Journal of Roentgenology 2007; 188(4): W334-W340.
  5. Soulez G, Pasowicz M, Benea G et al. Renal artery stenosis evaluation: diagnostic performance of gadobenate dimeglumine-enhanced MR angiography--comparison with DSA. Radiology 2008; 247(1): 273-285.
  6. National Imaging Associates, Inc. MR Angiography Abdomen, 2015.
  7. National Imaging Associates, Inc. MR Angiography Pelvis, 2015.
  8. Shih MC & Hagspiel KD. CTA and MRA in mesenteric ischemia: part 1, Role in diagnosis and differential diagnosis. American Journal of Roentgenology 2007; 188: 452-461.
  9. Shih MP, Angle JF, Leung DA et al. CTA and MRA in mesenteric ischemia: part 2, normal findings and complications after surgical and endovascular treatment. American Journal of Roentgenology 2007; 188: 462-471.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/26/15.

GUIDELINE UPDATE INFORMATION:

12/15/13

New Medical Coverage Guideline.

01/01/15

Review. Added indications for abdomen and pelvic MRA; vascular disease, pre-operative and post-operative or post-procedure evaluation. Updated references.

04/15/15

Annual review. No change to position statement. Revised description and updated references.

Date Printed: June 25, 2017: 01:26 PM