MRI (Magnetic Resonance Imaging) Cardiac Form
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MRI (Magnetic Resonance Imaging) Cardiac Medical Guideline
Service: MRI Cardiac
PUM 250-0052-1812
Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026
Description:
MRI Cardiac, or Cardiac Magnetic Resonance (CMR) looks at the vascular anatomy, function, perfusion, and tissue characteristics of the heart. Cardiac MR uses a strong magnetic field and does not expose the patient to ionizing radiation. Gadolinium contrast agents can be used, but the risks and benefits of these must be weighed carefully, particularly in patients with kidney or CNS disease. Since magnetic resonance uses strong magnetic fields, patients with implanted electrical devices, surgically placed hardware or implants may not be good candidates for this imaging.
Stress CMR for assessment of coronary artery disease (CAD) is performed pharmacologically by vasodilator perfusion imaging with gadolinium contrast; OR by dobutamine inotropic wall motion (ventriculography). Stress echocardiography (SE) or myocardial perfusion imaging (MPI) provide similar information about CAD.
Indications of Coverage:
A Cardiac MRI is considered medically necessary when at least ONE of the following criteria are met:
Congenital Heart Disease (CHD)--For all indications below, either CT or CMR can be done. CMR may be approved for ANY of the following:
A. Evaluation prior to planned repair and for post-operative follow-up after surgical repair.
B. Evaluation for change in clinical status with new concerning signs or symptoms.
C. Change in pulmonary arterial hypertension-targeted therapy.
D. Clinical suspicion of pulmonary hypertension following CHD surgery.
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E. Routine surveillance of CHD up to every 1-2 years, when no cardiac CT or MRI has been done in the last year.
F. Routine surveillance up to every 6 months in a child with aortic sinus and/or aortic dilation that is increasing in size.
G. Routine surveillance up to every 6 months in a patient with valvular or ventricular dysfunction, right or left ventricular outflow tract obstruction, or presence of an RV-to-PA conduit.
H. Postoperative follow-up after physiological repair with VSD (ventriculoseptal defect) closure and/or LV-to-PA (pulmonary artery) conduit: routine surveillance (every 3–12 months) in a patient with ≥ moderate systemic AV (atrioventricular) valve regurgitation, systemic RV (right ventricle) dysfunction, and/or LV-to-PA conduit dysfunction.
I. Ebstein’s anomaly and Tricuspid Valve dysplasia (only CMR indicated): For evaluation prior to planned repair and evaluation for change in clinical status or new concerning signs or symptoms.
J. Any known or suspected congenital heart disease and TTE/TEE is indeterminate.
Valvular Heart Disease – CMR may be approved for ANY of the following:
A. Bicuspid aortic valve with ascending aortic diameter greater than 4.0 cm, with surveillance up to 2 times per year provided at least ONE of the following is met:
i. Aortic diameter at least 4.5 cm
ii. First degree relative with aortic dissection
iii. Aortic diameter growth rate at least 5 mm per year, see 15. Below, Aortic Pathology
B. Evaluation of valvular stenosis, regurgitation, or valvular masses when TTE is inadequate. For surveillance of documented aortic pathology, see 15. Below, Aortic Pathology.
C. Pre-TAVR (transcatheter aortic valve replacement) assessment if the patient has not undergone cardiac CT.
D. Prior to transcatheter mitral valve intervention, when TTE and TEE (transesophageal echocardiogram) result in uncertain assessment of the severity of mitral regurgitation.
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E. Postprocedural assessment for regurgitation after percutaneous procedure on any cardiac valve.
F. Suspected clinically significant bioprosthetic valvular dysfunction and inadequate images from TTE and TEE.
Cardiomyopathy and heart failure – CMR may be approved for ANY of the following:
A. Suspected inherited or acquired cardiomyopathy
B. Newly diagnosed cardiomyopathy
C. Suspected infiltrative disease such as amyloidosis, sarcoidosis, hemochromatosis, or endomyocardial fibrosis if PET (positron emission tomography) has not been performed.
D. Known or suspected acute myocarditis, as indicated by ONE or more of the following:
i. An endocardial biopsy area requiring further characterization.
ii. A rise in troponin not clearly due to acute myocardial infarction iii. A change in ECG (electrocardiogram) suggesting acute myocardial injury, such as pericarditis, without evident myocardial infarction. iv. Indeterminate transthoracic echocardiography resultsE. Clinical symptoms and signs consistent with a cardiac diagnosis known to cause presyncope/syncope (including, but not limited to, hypertrophic cardiomyopathy).
F. Hypertrophic cardiomyopathy and TTE (trans thoracic echocardiogram) are indeterminate.
G. Up to Every 3 years in patient with Hypertrophic cardiomyopathy for the purpose of SCD (sudden cardiac death) risk stratification to evaluate changes in LGE, EF, development of apical aneurysm, or LV wall thickness.
H. Known or suspected arrhythmogenic right ventricular cardiomyopathy and ONE or more of the following:
i. Nonsustained ventricular tachycardia (VT) ii. Unexplained syncope iii. ECG abnormalities iv. First-degree relatives with positive genotype for ARVD (arrhythmogenic right ventricular dysplasia)
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I. TTE is suggestive of noncompaction Cardiomyopathy.
J. Pulmonary hypertension in the absence of severe valvular disease.
K. Known or suspected arrhythmogenic right ventricular dysplasia.
L. Transfusion dependent Beta-thalassemia.
M. Known or suspected Chagas disease with cardiomyopathy.
N. Coronary vein mapping when cardiac resynchronization therapy is planned.
Coronary Artery Disease Evaluation and at least ONE of the following:
A. Assessment of LV wall motion to identify patients with akinetic segments that would benefit from coronary revascularization.
B. Chronic or acute ischemic heart disease when used to identify the extent and location of myocardial necrosis in patients.
C. Follow-up of known CAD (coronary artery disease) with coronary stenosis of unclear significance on previous coronary angiography.
D. To diagnose microvascular dysfunction in patients with persistent stable anginal chest pain with suspected ischemia and nonobstructive coronary artery disease, ischemia and no obstructive coronary arteries (INOCA), as documented in provider notes.
E. To assess myocardial viability and distinguish hibernating myocardium from scarring, provided revascularization is being considered.
Initial evaluation of cardiac mass, suspected tumor or thrombus, or potential cardiac source of emboli.
Re-evaluation of intracardiac mass when findings would change therapy.
To differentiate constrictive vs restrictive physiology of pericardial disease when TTE/TEE is nondiagnostic.
Preoperative planning needed for pericardial surgery.
Ventricular septal defect, known or suspected, post myocardial infarction, when echocardiography results are indeterminate.
Known or suspected coronary aneurysms or anomalous coronary arteries.
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Pre-procedure Evaluation for Closure of ASD (atrial septal defect) or PFO (patent foramen ovale) – CMR may be approved for EITHER of the following:
A. For assessment of atrial septal anatomy and atrial septal aneurysm
B. For assessment of suitability for percutaneous device closure
Assessment Following LAA (left atrial appendage) Occlusion - For surveillance at 45 days post procedure.
Pre-Ablation Planning - Evaluation of left atrium and pulmonary veins prior to radiofrequency ablation for atrial fibrillation, if cardiac CT has not been done.
Post-Ablation--Assessment following left atrial and pulmonary vein radiofrequency ablation.
Aortic Pathology--CT, MR, or echocardiogram can be used for screening and follow-up, with CT and MR preferred for imaging beyond the proximal ascending thoracic aorta. CMR may be approved for ANY of the following:
A. Screening of first-degree relative with a bicuspid aortic valve.
B. Blunt chest trauma, penetrating aortic trauma, or iatrogenic trauma from aortic instrumentation, and CT scan contraindicated or not available.
C. Coarctation of the aorta, known or suspected.
D. Supravalvular aortic stenosis, known or suspected.
E. Thoracic aortic aneurysm or dilatation, known or suspected.
F. Six-month follow-up after initial diagnosis of thoracic aortic aneurysm.
G. Annual follow-up for an enlarged thoracic aortic aneurysm defined as > 4.4 cm.
H. Follow-up of enlarged aortic root > 4.5 cm or showing growth rate ≥ 0.5 cm/year, twice yearly.
I. Thoracic aortic dissection, known or suspected.
J. First-degree relative of patient with thoracic aortic aneurysm and/or dissection.
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K. Genetic predisposition to aortic disease, with imaging needed for initial diagnosis, regular surveillance based on specific condition, preconception planning, pregnancy monitoring, or postpartum evaluation.
L. Vasculitis affecting aorta (e.g., Takayasu arteritis, giant cell arteritis), known or suspected.
M. Re-evaluation of the size and morphology of the aortic sinuses and ascending aorta in patients with a bicuspid AV and an ascending aortic diameter >4 cm with ONE of the following:
i. Aortic diameter >4.5 cm ii. Rapid rate of change in aortic diameter iii. Family history (first-degree relative) of aortic dissection
N. Patients with Turner’s syndrome annually if a cardiac abnormality exists. If initial study normal, can have imaging every 5 - 10 years.
O. Preoperative planning needed for pericardial surgery.
Kawaski’s disease, when coronary artery disease is suspected on other imaging,
or TTE/TEE are nondiagnostic.
Requests for repeat MR imaging, after completing MR of the same anatomic site in the past 6 months, will be reviewed on a case-by-case basis. The most recent imaging reports must be submitted, and for the repeat exam to be approved as medically necessary, ONE of the following MUST be met:
a) documentation that the prior testing was inconclusive, or with short-term follow-up imaging recommended. b) clinical documentation of progressive worsening of symptoms or new physical exam findings prompting the repeat imaging, and that patient management will be altered by the imaging results.
c) interval surgery (with suspected complication) or significant new trauma to that anatomic region.
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Limitations of Coverage:
Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.” A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.
B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.
C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.
D. Cardiac MRI is considered not medically necessary for ANY the following:
a. Screening for asymptomatic patients who are at low risk for cardiac disease. b. Monitoring stable patients with known cardiac disease c. Guiding invasive procedures other than as specified under indications. d. Research purposes
Documentation Required:
Prior authorization is required for all cardiac MRI procedures. To obtain prior authorization, the requesting provider must submit the following information:
• A standard written order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis. • Medical record information (including continued need/use if applicable) and medical necessity. • Correct coding for the service that meets all coding guidelines.
Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an
explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage
for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan,
including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the
organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as
listed on the member card for specific plan, benefit, and network status information.
Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The
organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in
administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent
professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email
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medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered. State mandates, laws or benchmark supersede this medical guideline.
Imaging is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.
**All imaging related to cancer care, WPS uses NCCN as a primary reference.
Guideline Review History:
Implemented 01/01/24, 08/01/24, 09/01/25, 05/01/26 Medical Guideline Committee Approval 10/26/23, 07/25/24, 03/27/25, Q1 2026 Reviewed
10/26/23, 07/25/24, 03/27/25, Q1 2026 Developed 10/26/23
Approved by the Medical Director
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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.
Codes
Code Description
75557
Cardiac MRI, without Gadolinium contrast, for morphology and function
without stress
75559
Cardiac MRI, without Gadolinium contrast, for morphology and function with
stress
75561
Cardiac MRI, with Gadolinium contrast, for morphology and function without
stress
75563
Cardiac MRI, with Gadolinium contrast, for morphology and function with
stress
75565
Cardiac magnetic resonance imaging for velocity flow mapping (list separately
in addition to code for primary procedure)
C9762
Cardiac magnetic resonance imaging for morphology and function,
quantification of segmented dysfunction; with strain imaging
C9763
Cardiac magnetic resonance imaging for morphology and function,
quantification of segmented dysfunction; with stress imaging
0992T
Noninvasive assessment of cardiac risk derived from augmentative software
analysis of perivascular fat without concurrent computed tomography (CT)
scan of the hear, including patient-specific clinical factors, with interpretation
and report by a physician or other qualified health care professional
0993T
Noninvasive assessment of cardiac risk derived from augmentative software
analysis of perivascular fat with concurrent computed tomography scan of the
heart, including patient-specific clinical factors, with interpretation and report
by a physician or other qualified health care professional (list separately in
addition to code for primary procedure)
ASSOCIATED CODES
A9573
Injection, Gadopiclenol, 1 ml
A9575
Injection, Gadoterate Meglumine, 0.1 ml
A9577
Injection, Gadobenate Dimeglumine (Multihance), per ml
A9578
Injection, Gadobenate Dimeglumine (Multihance Multipack), per ml
A9579
Gadolinium based magnetic resonance contrast agent, per ml
A9585
Injection, Gadobutrol, 0.1 ml
J0152
Adenosine injection, per 30 mg
J1245
Dipyridammole injection, per 10 mg
J1250
Dobutamine HCL injection, per 250 mg
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Review how this policy can be converted into cited criteria, prior authorization checks, and operational automation.