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Date Printed: August 23, 2017: 06:10 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.

04-70540-13

Original Effective Date: 07/01/07

Reviewed: 12/04/14

Revised: 01/01/15

Subject: Magnetic Resonance Imaging (MRI) Chest and Cardiac

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 Update    
           

DESCRIPTION:

Magnetic resonance imaging (MRI) is a radiation-free, noninvasive, technique used to produce high quality sectional images of the inside of the body in multiple planes. MRI uses natural magnetic properties of the hydrogen atoms in the body that emit radiofrequency signals when exposed to radio waves within a strong magnetic field. These signals are processed and converted by a computer into high-resolution, three-dimensional, tomographic images. Images and resolution produced by MRI is quite detailed. For some MRI, contrast materials (e.g., gadolinium, gadoteridol, non-ionic and low osmolar contrast media, ionic and high osmolar contrast media) are used to enable visualization of a body system or body structure.

The U.S. Food and Drug Administration’s (FDA) cleared MRI systems for marketing through the 510(k) process. The Fonar Stand-Up MRI system received FDA marketing clearance in October 2000.

POSITION STATEMENT:

Magnetic resonance imaging (MRI) of the chest and heart meets the definition of medical necessity for the following:

INDICATIONS FOR CHEST MRI:

INDICATIONS FOR CARDIAC MRI:

Where stress echocardiography (SE) is noted as an appropriate substitute according to the American College of Cardiology Foundation (ACCF) Appropriateness Criteria for cardiac magnetic resonance imaging (MRI) for indications (2, 3, 4, 12, and 13) in Table 1a, 2a and 3a AND at least one of the following contraindications to SE must be documented in the member’s medical record:

OR

Cardiac MRI is the preferred diagnostic imaging to stress echocardiography for the following, including, but not limited to following conditions:

OR

All other requests for cardiac MRI, the member must meet the ACCF cardiac magnetic resonance imaging Appropriateness Criteria Score (4-9) in Table 1a, 2a and 3a.

Indications in the American College of Cardiology Foundation (ACCF) Appropriateness Criteria for cardiac magnetic resonance imaging with an Appropriate Use Score (1-3; Inappropriate (I)) noted in Table 4a OR any one of the following do not meet the definition of medically necessity:

ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2010 APPROPRIATE USE CRITERIA for CARDIAC MRI:

Where there is other ACCF reviewed imaging modalities, a crosswalk shows the relative appropriate use score between the two equivalent elements.

Table 1a Detection of CAD: Symptomatic

Heart MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score

A= Appropriate (7-9)

U= Uncertain (4-6)

Indications

(*Refer to additional information section

Other imaging modality cross-walk: stress echocardiography (SE) and chest CTA (CCTA)

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score

Evaluation of Chest Pain Syndrome (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

2 U (4)

  • Intermediate pre-test probability of CAD*
  • ECG interpretable AND able to exercise

SE 116 A (7)

3 A (7)

  • Intermediate pre-test probability of CAD*
  • ECG interpretable OR unable to exercise

SE 117 A (9)

4 U (5)

  • High pre-test probability of CAD*

SE 118 A (7)

Evaluation of Intra-Cardiac Structures (Use of MR Coronary Angiography)

8 A (8)

  • Evaluation of suspected coronary anomalies

CCTA 46 A (9)

Acute Chest Pain (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

9 U (6)

  • Intermediate pre-test probability of CAD
  • No ECG changes and serial cardiac enzymes negative

CCTA 6 A (7)

Risk Assessment With Prior Test Results (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

12 U (6)

  • Intermediate CHD risk (Framingham)
  • Equivocal stress test (exercise, stress SPECT, or stress echo)

SE 153 A (8)

13 A (7)

  • Coronary angiography (catheterization or CT)
  • Stenosis of unclear significance

SE 141 A (8)

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery – Intermediate or High Risk Surgery (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

15 U (6)

  • Intermediate perioperative risk predictor
 

Table 2a Structure and Function

Cardiac MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score

A= Appropriate (7-9)

U= Uncertain (4-6)

Indications

(*Refer to additional information section)

Other imaging modality cross-walk: stress echocardiography (SE) and chest CTA (CCTA)

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score

Evaluation of Ventricular and Valvular Function

Procedures may include LV/RV mass and volumes, MR angiography, quantification of valvular disease and delayed contrast enhancement

18 A (9)

  • Assessment of complex congenital heart disease including anomalies of coronary circulation, great vessels, and cardiac chambers and valves
  • Procedures may include LV/RV mass and volumes, MR angiography, quantification of valvular disease, and contrast enhancement

CCTA 47 A (8)

19 U (6)

  • Evaluation of LV function following myocardial infarction OR in heart failure members
 

20 A (8)

  • Evaluation of LV function following myocardial infarction OR in heart failure members
  • Members with technically limited images from echocardiogram
 

21 A (8)

  • Quantification of LV function
  • Discordant information that is clinically significant from prior tests
 

22 A (8)

  • Evaluation of specific cardiomyopathies (infiltrative (amyloid, sarcoid), HCM, or due to cardiotoxic therapies)
  • Use of delayed enhancement
 

23 A (8)

  • Characterization of native and prosthetic cardiac valves—including planimetry of stenotic disease and quantification of regurgitant disease
  • Members with technically limited images from echocardiogram or TEE
 

24 A (9)

  • Evaluation for arrythmogenic right ventricular cardiomyopathy (ARVC)
  • Members presenting with syncope or ventricular arrhythmia
 

25 A (8)

  • Evaluation of myocarditis or myocardial infarction with normal coronary arteries
  • Positive cardiac enzymes without obstructive atherosclerosis on angiography
 

Evaluation of Intra- and Extra-Cardiac Structures

26 A (9)

Evaluation of cardiac mass (suspected tumor or thrombus)

Use of contrast for perfusion and enhancement

 

27 A (8)

Evaluation of pericardial conditions (pericardial mass, constrictive pericarditis)

 

28 A (8)

Evaluation for aortic dissection

 

29 A (8)

Evaluation of pulmonary veins prior to radiofrequency ablation for atrial fibrillation

Left atrial and pulmonary venous anatomy including dimensions of veins for mapping purposes

Chest CTA 38 A (8)

Table 3a Detection of Myocardial Scar and Viability

Cardiac MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score

A= Appropriate (7-9)

U= Uncertain (4-6)

Indications

(*Refer to reimbursement information section)

Other imaging modality cross-walk: stress echocardiography (SE) and chest CTA (CCTA)

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score

Evaluation of Myocardial Scar (Use of Late Gadolinium Enhancement)

30 A (7)

• To determine the location, and extent of myocardial necrosis including ‗no reflow‘ regions

• Post-acute myocardial infarction

 

31 U (4)

• To detect post PCI myocardial necrosis

 

32 A (9)

• To determine viability prior to revascularization

• Establish likelihood of recovery of function with revascularization (PCI or CABG) or medical therapy

 

33 A (9)

• To determine viability prior to revascularization

• Viability assessment by SPECT or dobutamine echo has provided "equivocal or indeterminate" results

 

INAPPROPRIATE USE INDICATIONS

Table 4a Detection of CAD: Symptomatic

Cardiac MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score)

Indications

(*Refer to additional information section

Appropriate Use Score (1-3)

I= Inappropriate

Evaluation of Chest Pain Syndrome (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

1

• Low pre-test probability of CAD

  • ECG interpretable AND able to exercise

I (2)

Evaluation of Chest Pain Syndrome (Use of MR Coronary Angiography)

5

• Intermediate pre-test probability of CAD

• ECG interpretable AND able to exercise

I (2)

6

• Intermediate pre-test probability of CAD

• ECG uninterpretable OR unable to exercise

I (2)

7

• High pre-test probability of CAD

I (1)

Acute Chest Pain (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

10

• High pre-test probability of CAD

• ECG - ST segment elevation and/or positive cardiac enzymes

I (1)

Risk Assessment With Prior Test Results (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

11

• Normal prior stress test (exercise, nuclear, echo, MRI)

• High CHD risk (Framingham)

• Within 1 year of prior stress test

I (2)

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery – Low Risk Surgery (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

14

• Intermediate perioperative risk predictor

I (2)

Table 5a Detection of CAD: Post-Revascularization (PCI or CABG)

Cardiac MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score)

Indications

(*Refer to additional information section.)

Appropriate Use Score (1-3)

I= Inappropriate

Evaluation of Chest Pain Syndrome (Use of MR Coronary Angiography)

16

  • Evaluation of bypass grafts

I (2)

17

  • History of percutaneous revascularization with stents

I (1)

BILLING/CODING INFORMATION:

CPT Coding

71550

Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)

71551

Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)

71552

Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequence

75557

Cardiac magnetic resonance imaging for morphology and function without contrast material;

75559

Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging

75561

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;

75563

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging

75565

Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)

HCPCS Coding

S8042

Magnetic resonance imaging (MRI), low-field

REIMBURSEMENT INFORMATION:

Reimbursement for magnetic resonance imaging chest (71550, 71551, and 71552) and cardiac magnetic resonance imaging (75557, 75559, 75561, 75563, and 75565) is limited to one (1) cardiac magnetic resonance imaging within a 6-month period. Magnetic resonance imaging of the chest and cardiac magnetic resonance imaging in excess of one (1) within a 6-month period is subject to medical review for medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Additional MRI imaging of the same anatomical area may be appropriate for the following, including, but not limited to: diagnosis, staging or follow-up of cancer, follow-up assessment during or after therapy for known metastases, follow-up of member who have had an operative, interventional or therapeutic procedure (e.g., surgery, embolization), reevaluation due to change in clinical status (e.g., deterioration), new or worsening clinical findings, (e.g., neurologic signs, symptoms), medical intervention which warrants reassessment, reevaluation for treatment planning, follow-up during and after completion of therapy or treatment to assess effectiveness, and evaluation after intervention or surgery.

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

Open MRI Units (Stand-Up MRI/Sitting MRI-Positional MRI)

Open MRI units of any configuration, including MRI units that allow imaging when standing (Stand-up MRI) or when sitting (Sitting MRI), are considered to be an acceptable standard alternative to standard “closed” MRI units. Stand-up MRI and sitting MRI may be reported like a standard MRI. No additional payment will be made for stand-up MRI or sitting MRI.

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 imaging (MRI) chest and cardiac.

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

Determination of Pretest Probability for Coronary Artery Disease (CAD)

Table 1: Determination of Pretest Probability for Coronary Artery Disease Based on Age, Gender, and Symptoms (Source: American College of Cardiology Criteria for Pretest Probability of Coronary Artery Disease (CAD).

The following risk assessment may be used to determine pre-test probability of coronary artery disease.

Table 1:

Age (years)

Gender

Typical/Definite Angina Pectoris

Atypical/Probable Angina Pectoris

Nonanginal Chest Pain

Asymptomatic

30 – 39

Men

Intermediate

Intermediate

Low

Very low

 

Women

Intermediate

Very low

Very low

Very low

40 – 49

Men

High

Intermediate

Intermediate

Low

 

Women

Intermediate

Low

Very low

Very low

50 – 59

Men

High

Intermediate

Intermediate

Low

 

Women

Intermediate

Intermediate

Low

Very low

60 – 69

Men

High

Intermediate

Intermediate

Low

 

Women

High

Intermediate

Intermediate

Low

High: Greater than 90% pre-test probability of CAD

Intermediate: Between 10% and 90% pre-test probability of CAD

Low: Between 5% and 10% pre-test probability of CAD

Very low: Less than 5% pre-test probability of CAD

Angina: As defined by the American College of Cardiology (ACC)/American Heart Association (AHA)

Typical Angina (Definite): 1.) Substernal chest pain or discomfort that is 2.) Provoked by exertion or emotional stress and 3.) Relieved by rest and/or nitroglycerine.

Atypical Angina (Probable): Chest pain or discomfort that lacks one of the characteristics of definite or typical angina.

Non-Anginal Chest Pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.

Framingham Risk Assessment for Coronary Heart Disease (CHD) Risk

Table 2: Framingham Risk Assessment for Coronary Heart Disease (CHD) Risk

Framingham risk assessment is a calculation to predict the 10-year risk of heart disease. The calculation is based on the individual’s age, sex, most recent lipid values, blood pressure, smoking history, and presence of diabetes.

Table 2:

CHD Risk Level

Framingham Score

CHD Risk-Low Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CHD risk.

Less than 10%

CHD Risk-Moderate Defined by the age-specific risk level that is average or above average.

Between 10% and 20%

CHD Risk-High Defined as the presence of diabetes mellitus.

Greater than 20%

Determining Preoperative Risk

*Perioperative Risk Predictors

As defined by the *ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation of Non-Cardiac Surgery

Major risk predictors

Intermediate risk predictors

Minor risk predictors

*Surgical Risk Categories

As defined by the *ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation of Non-Cardiac Surgery)

High-Risk Surgery—cardiac death or MI greater than 5%

Intermediate-Risk Surgery—cardiac death or MI = 1% to 5%

Low-Risk Surgery—cardiac death or MI less than 1%

ECG–Uninterpretable

Refers to ECGs with resting ST-segment depression (greater than or equal to (≥) 0.10 mV), complete LBBB, pre-excitation (Wolff-Parkinson-White Syndrome), or paced rhythm.

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 Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

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

Medicare Advantage:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Magnetic Resonance Imaging, (220.2) located at cms.gov.

DEFINITIONS:

Brachial plexopathy: any neuropathy of the brachial plexus, also called brachial plexus neuropathy, brachial syndrome, and cervicobrachial syndrome.

Cardiomyopathies: a general diagnostic term designating primary noninflammatory disease of the heart muscle, often of obscure or unknown etiology and not the result of ischemic, hypertensive, congenital, valvular, or pericardial disease. Cardiomyopathies are usually subdivided into dilated, hypertrophic, and restrictive.

Myocardial infarction: gross necrosis of the myocardium as a result of interruption of the blood supply to the area; it is almost always caused by atherosclerosis of the coronary arteries, upon which coronary thrombosis is usually superimposed.

Electrogradiogram (ECG)-uninterpretable: ECGs with resting ST-segment depression (less than or equal to 1.10 mV), complete left bundle-branch block (LBBB), pre-excitation Wolff-Parkinson-White syndrome (WPW) or paced rhythm.

RELATED GUIDELINES:

Magnetic Resonance Spectroscopy (MRS), 04-70540-07
Magnetic Resonance Imaging (MRI) of the Breast, 04-70540-09

Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck, 04-70540-12

Magnetic Resonance Imaging (MRI) Abdomen and Pelvis, 04-70540-14

Magnetic Resonance Imaging (MRI) Upper Extremity, 04-70540-15

Magnetic Resonance Imaging (MRI) Lower Extremity, 04-70540-16

Magnetic Resonance Imaging (MRI) Spine (Cervical, Thoracic, Lumbar), 04-70540-17

OTHER:

Other names used to report MRI:

Nuclear Magnetic Resonance (NMR)
Open MRI

Other names used to report Positional MRI:

Position MRI (pMRI)
Sitting MRI
Stand-Up MRI
Standing MRI
Weight-bearing MRI

Abbreviations

ACCF = American College of Cardiology Foundation

ACS = acute coronary syndrome

ACR = American College of Radiology

ASNC = American Society of Nuclear Cardiology

BMI = body mass index

CABG = coronary artery bypass grafting surgery

CAD = coronary artery disease

CCTA = coronary CT angiography

CHD = coronary heart disease

CHF = congestive heart failure

CT = computed tomography

CTA = computed tomographic angiography

ECG = electrocardiogram

ERNA = equilibrium radionuclide angiography

FEV1 = forced expiratory volume

FP = First Pass

GOLD = Global initiative for chronic obstructive lung disease

HF = heart failure

LBBB = left bundle-branch block

LV = left ventricular

MET = estimated metabolic equivalent of exercise

MI = myocardial infarction

MPI = myocardial perfusion imaging

MRA = magnetic resonance angiography

MRI = magnetic resonance imaging

NASCI = North American Society for Cardiac Imaging

PCI = percutaneous coronary intervention

PET = positron emission tomography

RNA = radionuclide angiography

SCAI = Society for Cardiovascular Angiography and Interventions

SCCT = Society for Cardiovascular Magnetic Resonance

SE = stress echocardiography

SIR = Society of Interventional Radiology

SPECT = single positron emission CT (see MPI)

REFERENCES:

  1. ACR-NASCI-SPR Practice Parameter for the Performance and Interpretation of Cardiac Magnetic Resonance Imaging (MRI), 2014.
  2. Blue Cross Blue Association Positional Magnetic Resonance Imaging (MRI) (6.01.04), 04/14.
  3. Centers for Medicare & Medicaid Services NCD for Magnetic Resonance Imaging (220.2), 06/03/10.
  4. Hendel RC, Patel MR, Kramer CM et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. Journal of the American college of Cardiology 2006; 48(7): 1475-1497.
  5. National Imaging Associates, Inc. Clinical Guidelines Chest (Thorax) MRI, 05/13.
  6. National Imaging Associates, Inc. Clinical Guidelines Heart MRI, 07/13.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/04/14.

GUIDELINE UPDATE INFORMATION:

07/01/07

New Medical Coverage Guideline.

01/01/08

HCPCS update. Deleted 75552, 75553, 75554, 75555, and 75556. Added 75557, 75558, 75559, 75560, 75561, 75562, 75563, and 75564.

01/21/08

Updated Program Exceptions.

07/15/08

Scheduled review. No change in position statement. Updated references and related Internet links.

05/21/09

Removed Federal Employee Plan (FEP) from BCBSF Radiology Management program exception statement. Added FEP program exception statement: FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

07/01/09

Updated BCBSF Radiology Management program exception; added BlueSelect.

11/15/09

Code update; added 71552.

01/01/10

Annual HCPCS coding update: deleted 75558, 75560, 75562, and 75564. Added 75565. Revised BCBSF Radiology Management program exception section, and updated the references.

07/15/10

Annual review: deleted 77084 and updated references.

09/15/11

Scheduled review; revised position statements. Deleted 77084. Updated definitions and references.

10/01/11

Revision; formatting changes.

12/15/12

Annual review; added indications for chest and cardiac MRI and appropriate use criteria and table for cardiac MRI. Added inappropriate indications for cardiac MRI. Added criteria for imaging which exceed limit. And statement for re-imaging or additional imaging. Added Medicare Advantage program exception (nationally non-covered indications) for MRI of cortical bone and calcifications and procedures involving spatial resolution of bone and calcifications. Updated references.

01/01/14

Review. Updated program exception and references.

01/01/15

Scheduled review; maintain position statement. Updated references.

Date Printed: August 23, 2017: 06:10 AM