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Date Printed: October 23, 2017: 02:17 AM

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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.

04-70540-22

Original Effective Date: 12/15/13

Reviewed: 03/26/15

Revised: 04/15/15

Subject: Magnetic Resonance Angiography (MRA) Extremity (Upper and Lower)

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 alternative to catheter angiography for evaluation of vascular structures in the upper extremity and for imaging arterial obstructive disease in the lower extremity. In the upper extremity, magnetic resonance venography (MRV) may be used to image veins instead of arteries. MRA and MRV are less invasive than conventional x-ray digital subtraction angiography. In the lower extremity, MRA may be used to image tibia and pedal arteries and evaluate symptoms that occur after angiography. A contrast material (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 extremity (upper and lower) 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 upper extremity meets the definition of medical necessity for the following:

Assessment/evaluation of known or suspected vascular disease/condition:

Evaluation of suspected vascular disease aneurysm, arteriovenous malformation, fistula, vasculitis, or intramural hematoma

Evaluation of vascular invasion or displacement by tumor

Evaluation of complications of interventional vascular procedures (e.g., pseudoaneurysms related to surgical bypass grafts, vascular stents, or stent-grafts)

Evaluation of suspected upper extremity embolism or venous thrombosis

Preoperative evaluation:

Preoperative evaluation from known vascular disease/condition

Post-operative/ procedural evaluation:

A follow-up study may be needed to 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 areas(s) requested

 

Magnetic resonance angiography (MRA) of the lower extremity meets the definition of medical necessity for the following:

Assessment/evaluation of suspected or known vascular disease/condition:

Significant ischemia in the presence of ulcers/gangrene

Large vessel diseases (e.g., aneurysm, dissection, arteriovenous malformations (AVMs), and fistulas, intramural hematoma, and vasculitis)

Arterial entrapment syndrome (e.g. peripheral artery disease (PAD))

Venous thrombosis if previous studies have not resulted in a clear diagnosis

Vascular invasion or displacement by tumor

Pelvic vein thrombosis or thrombophlebitis

Abnormal preliminary testing (Ankle/Brachial index, ultrasound/doppler arterial evaluation) associated with significant symptoms of claudication with exercise

Pre-operative evaluation:

Evaluation of known aortoiliac occlusion or peripheral vascular disease of the leg and ultrasound indicates significant disease and an indeterminate conclusion about whether the condition would be amenable to surgery

Post- operative/procedural evaluation:

Post-operative or interventional vascular procedure for luminal patency versus re-stenosis (due to atherosclerosis, thromboembolism, intimal hyperplasia and other causes) as well as complications such as pseudoaneurysms related to surgical bypass grafts and vascular stents and stent-grafts

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:

73225

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

73725

Magnetic resonance angiography, lower extremity, 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 extremity (upper and lower).

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) Abdomen and Pelvis, 04-70540-21

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

OTHER:

None applicable.

REFERENCES:

  1. American College of Radiology ACR Appropriateness Criteria®: Chronic Elbow Pain, 2011.
  2. American College of Radiology ACR Appropriateness Criteria®: Claudication-Suspected Vascular Etiology, 2012.
  3. American College of Radiology ACR Appropriateness Criteria®: Follow-up of Lower-Extremity Arterial Bypass Surgery, 2013.
  4. American College of Radiology ACR Appropriateness Criteria®: Recurrent Symptoms Following Lower-Extremity Angioplasty, 2012.
  5. American College of Radiology ACR Appropriateness Criteria®: Suspected Upper Extremity Deep Vein Thrombosis, 2011.
  6. American College of Radiology ACR Appropriateness Criteria®: Upper Extremity Swelling, 2014.
  7. ACR-NASCI-SPR Practice Guideline for the Performance of Body Magnetic Resonance Angiography (MRA), 2014.
  8. Bezooijen R, van den Bosch HCM, Tiebeek AV et al. Peripheral arterial disease: sensitivity-encoded multiposition MR angiography compared with intraarterial angiography and conventional multiposition MR angiography. Radiology 2004; 231(1): 263-271.
  9. Bilecen D, Aschwanden M, Heidecker HG et al. Optimized assessment of hand vascularization on contrast-enhanced MR angiography with a subsystolic continuous compression technique. American Journal of Radiology 2004; 182(1): 180-182.
  10. Karcaaltincaba M, Akata D, Aydingoz U et al. Three-dimensional MDCT angiography of the extremities: clinical applications with emphasis on musculoskeletal uses. American Journal of Radiology 2004; 183(1): 113-117.
  11. National Imaging Associates, Inc.MR Angiography Upper Extremity, 2015.
  12. National Imaging Associates, Inc.MR Angiography Lower Extremity, 2015.
  13. Zhang, H.L., Khilnani, N.M., Prince, M.R., et al. Diagnostic accuracy of time-resolved 2D projection MR angiography for symptomatic infrapopliteal arterial occlusive disease. American Journal of Radiology 2005; 184(3): 938-947.

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 23, 2017: 02:17 AM