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Date Printed: October 17, 2017: 04:28 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.

04-70540-20

Original Effective Date: 12/15/13

Reviewed: 03/26/15

Revised: 04/15/15

Subject: Magnetic Resonance Angiography (MRA) Chest

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 used to provide cross-sectional and projection images of the thoracic vascular, including large and medium size vessels (e.g., thoracic aorta). MRA provides images of normal as well as diseased blood vessels and quantifies blood flow through these blood vessels. A contrast agent (gadolinium) may be used to enable visualization of a body system or body structure 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 chest 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 chest meets the definition of medical necessity for the following:

Evaluation of suspicious mass and computed tomographic angiography (CTA) is contraindicated due to allergy to iodinated contrast or member is at high risk for contrast induced renal failure

Evaluation of suspected or known pulmonary embolism

Evaluation of suspected or known vascular abnormalities

Thoracic aortic aneurysm or thoracic aortic dissection

Congenital thoracic vascular anomaly, (e.g., coarctation of the aorta or evaluation of a vascular ring suggested by GI study)

Signs or symptoms of vascular insufficiency of the neck or arms (e.g., subclavian steal syndrome with abnormal ultrasound)

Follow-up evaluation of progressive vascular disease when new signs or symptoms (e.g., pain/swelling of an extremity, decreased or absent pulse, weakness, numbness, paralysis) are present

Pulmonary hypertension

Preoperative evaluation

Known vascular abnormalities and patient has not had a catheter angiogram within the last month.

Proposed ablation procedure for atrial fibrillation

Postoperative or post-procedural evaluation

Known vascular abnormalities with physical evidence of post-operative bleeding complication or re-stenosis

Request for a follow-up study (a follow-up study may be needed to help evaluate a member’s progress after treatment, procedure, intervention or surgery). Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

BILLING/CODING INFORMATION:

CPT Coding:

71555

Magnetic resonance angiography, chest (excluding myocardium), 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 chest.

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) Abdomen and Pelvis, 04-70540-21

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®: Acute Chest Pain-Suspected Pulmonary Embolism, 2011.
  2. American College of Radiology ACR Appropriateness Criteria®: Acute Chest Pain-Suspected Aortic Dissection, 2014.
  3. ACR-NASCI-SPR Practice Guideline for the Performance of Body Magnetic Resonance Angiography (MRA), 2014.
  4. American College of Radiology ACR Appropriateness Criteria®: Known or Suspected Congenital Heart Disease in the Adult, 2011.
  5. National Imaging Associates, Inc. MR Angiography Chest (excluding myocardium), 2015.

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.

04/15/15

Annual review. Revised description and position statement. Updated references.

Date Printed: October 17, 2017: 04:28 PM