MRI (Magnetic Resonance Imaging) of Upper and Lower Extremities Form

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MRI (Magnetic Resonance Imaging) of Upper and Lower Extremities Medical Guideline

Service: MRI of Upper and Lower Extremities

PUM 250-0058-1812

Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026

Description: Magnetic Resonance Imaging (MRI) of the extremities and musculoskeletal system allows for imaging of joints and adjacent structures without the use of radiation.
It provides high contrast and spatial resolution, allowing for detection of abnormalities of bone, cartilage, ligaments, tendons, and pathology of the periarticular structures and muscles.

Indications of Coverage:

MRI of the Upper or Lower Extremities is considered medically necessary when at least ONE of the following criteria are met:

The following applications (A. through N.) of musculoskeletal MRI apply to both the upper and lower Extremity.

A. Non-Contrast MRI for Trauma/ Fracture is considered medically necessary for ANY of the following:

a. better evaluation of comminuted or displaced fracture seen on plain radiographs (x-rays), or for presurgical planning.

b. for suspected acute, occult scaphoid fracture, talus, tarsal navicular, great toe sesamoid, or hip/femoral neck fracture or Lisfranc Fracture-dislocation of the midfoot and initial radiographs are not definitive, or do not demonstrate a clinically suspected fracture.

c. stress/insufficiency or occult subacute fractures when clinical exam and plain radiographs are not definitive and EITHER:

1) x-rays nondiagnostic after ten days conservative treatment OR
2) initial x-rays obtained at least 14 days after injury/ onset of

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symptoms are non-diagnostic, or do not demonstrate a clinically suspected stress fracture.

d. for suspected shin splints/stress reaction only if x-rays are non-diagnostic AND there has been failure of a four-week trial of provider-directed conservative care. **Repeating an MRI within 3 months after an initial MRI showing stress fracture/stress reaction is considered not medically necessary.

e. for suspected delayed union/nonunion of fracture/osteotomy/surgical fusion and no documented healing on two sets of x-rays at least 4 months apart (typically, CT is preferable).

f. with fracture documented on radiographs/imaging, for suspected associated ligamentous/tendinous injury that may require surgery.

g. to better evaluate a pathologic fracture seen on x-ray or CT.

h. with pathologic lesion (such as metastasis) and concern for impending fracture.

B. MRI for suspected Avascular Necrosis (AVN) is medically necessary when the anatomic site is one of the following: femoral head, distal femur/knee, talus, tarsal navicular, metatarsal head, humeral head, carpal lunate or scaphoid/wrist AND ONE of the following:

a. plain x-rays are negative or indeterminate, but patient is high risk (steroid use, organ transplant, alcohol abuse, sickle cell anemia).

b. plain radiographs are suggestive of or confirmatory of AVN, but MRI needed for appropriate treatment planning.

c. Known osteonecrosis, and need to evaluate contralateral joint, after x- rays obtained.

C. Non-Contrast MRI for Ganglion: When history/physical examination/radiographs do not provide a definitive diagnosis, or when needed for preoperative surgical planning.

D. MRI without or with contrast for Infection:

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a. when plain radiographs are negative or non-diagnostic, but soft tissue or bone infection is still suspected, OR

b. when radiographs are suggestive of infection/osteomyelitis, but MRI needed to evaluate extent of infection, or assess for skip lesions of for liquefied abscess which might be drained, OR

c. suspected septic joint when arthrocentesis is either contraindicated or unsuccessful or non-diagnostic, AND

i. ONE of the following exam findings (warm, swollen joint), decreased ROM, or fever AND
ii. ONE of the following: lab tests, either elevated WBC count, or elevated CRP/sedimentation rate (ESR), or aspiration had been completed, but analysis of joint fluid is nondiagnostic.

d. with septic joint confirmed by aspiration, and MRI needed to determine soft tissue extension and potential skip lesions.

e. soft tissue ulcer (diabetic or pressure or ischemic) or neuropathic joint and clinical signs of infection and osteomyelitis or deep infection/abscess are suspected.

f. for postoperative assessment of complication/possible infection with abnormal physical exam findings (such as fever) or lab findings (leukocytosis, elevated ESR/CRP).

E. MRI of soft Tissue Masses are medically necessary when ONE of the following are met:

a. plain radiographs and/or Ultrasound are negative or indeterminate (radiographs not required in patients with known malignancy), OR

b. to evaluate suspected vascular malformation and results will change management, OR

c. for revaluation, post treatment

F. For Bone or Soft Tissue Lesion /Mass: MRI is medically necessary if ONE of the following are met:

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a. radiographs or other imaging (such as bone scan) have been obtained, and diagnosis is uncertain based upon plain appearance (radiographs are not required if other imaging, such as bone scan, documents bony lesion).

b. MRI required for staging of tumor or for biopsy planning or to determine extent of disease for surgical or treatment planning.

c. with known underlying bone tumor/disorder (such as osteochondroma) and malignant degeneration is suspected.

d. for follow-up of known tumor, having been treated in the past 12 months.

e. to evaluate for potential metastases and/or tumor recurrence, and results will alter management. G. For Tendon or Muscle Injury: MRI is considered medically necessary when one of the following is met:
a. Known or suspected acute or subacute partial or complete tendon tear as demonstrated by abnormal or equivocal exam
b. Trial of 4 weeks of active conservative therapy within the past six months or during the current episode of pain without improvement.**
c. Tendon or muscle injury seen by other imaging and requiring MRI for treatment planning. Note: For suspected rotator cuff tear/injury refer to P. b (below). H. For Osteochondral Injuries (osteochondral fracture/osteochondritis dissecans), MRI is considered medically necessary, provided there is clinical suspicion and x-rays were nondiagnostic, or showed findings requiring additional imaging.

I. For post-operative evaluation when other imaging or physical exam or laboratory findings suggest infection or delayed union/nonunion, or other surgical/procedural complication.

J. MRI is medically necessary for evaluation of loose bodies in the joint, and x- rays were nondiagnostic, or showed findings requiring additional imaging.

K. For Inflammatory arthritis, Including Rheumatoid Arthritis, MRI without and with contrast is medically necessary of the symptomatic joint, or if multiple joints are affected, of the most symptomatic joint if ONE of the following:

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a. To help make a diagnosis of inflammatory arthritis (when evaluated by a specialist in rheumatology), when the diagnosis is uncertain despite x-rays (and/or ultrasound), lab results, history and physical examination.

b. patient has suspected seronegative RA and drug therapy is to be initiated.

c. to assess efficacy of disease modifying anti-rheumatic drug treatment (testing should only be approved for a single joint/anatomic site, and only once, not intended for routine follow-up).

d. to determine if a change in treatment is indicated.

L. With suspected joint prosthesis loosening or dysfunction, MRI is considered medically necessary if ANY of the following are met:

a. loosening/dysfunction suspected, and radiographs are non-definitive.

b. suspected metallosis with hip pain and metal on metal hip arthroplasty.

c. suspected peri-articular fracture and plain radiographs are not diagnostic.

M. Peripheral Nerve injury/entrapment (such as carpal tunnel syndrome or brachial plexopathy or tarsal tunnel or Morton’s neuroma), MRI is medically necessary if ONE of the following:

a. EMG or Nerve conduction study is abnormal, or if objective weakness is noted on physical exam.

b. failure of 4 weeks of conservative treatment.

N. For evaluation of foreign bodies, if x-ray or ultrasound or CT are non-diagnostic.

O. For diagnosis or biopsy planning or to monitor response to therapy of known or suspected inflammatory myopathies (such as dermatomyositis).

P. Osteoarthritis (OA)-When there are persisting pain/symptoms with failure of four-week trial of conservative therapy** (PT/Chiro, and/or provider directed HEP) within the past 6 months, OR worsening of symptoms during conservative treatment AND at least ONE of the following are met:

a. Known or suspected OA at earlier stages of the disease and x-ray is non-diagnostic.

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b. Clinical need for assessing pathology in other structures of the joint not visualized by radiography, such as effusions, synovium, menisci, and ligaments. c. Strong clinical suspicion is documented for pathologies other than OA that can be a cause of symptoms.

Q. If none of the above (A-O) are met, MRI of the Upper Extremity (Hand, Wrist, Arm, Elbow, Shoulder) is medically necessary if ONE of the following are met:

a. No joint specific physical exam findings on exam but persisting pain/symptoms with failure of four-week trial of conservative therapy** (PT/Chiro, and/or provider directed HEP) within the past 6 months, OR worsening of symptoms during conservative treatment.

b. Positive site-specific orthopaedic exam findings, to include (but not limited to):

i. shoulder—Physical exam findings suggesting shoulder laxity or instability; OR physical exam findings suspicious for rotator cuff tear, as indicated by rotator cuff weakness (e.g., positive belly-off sign or belly-press test, positive external rotational lag, positive internal rotational lag, or asymmetric weakness of shoulder abduction or external rotation). NOTE: Positive Neer or Hawkins test for impingement meet these criteria only if other findings suggest rotator cuff tear/weakness. ii. elbow –such as biceps squeeze test, bicipital aponeurosis flex test. iii. testing suggesting tear of scapholunate ligament or lunotriquetral ligament or press test for TFCC tear.

c. Joint instability on exam or recurrent joint dislocations.

d. marked joint swelling (or joint effusion) after acute trauma and following orthopaedic evaluation.

R. If none of the above, (A-O) are met, MRI of the lower extremity (bony pelvis, hip, knee, leg, ankle, foot) is medically necessary if ONE of the following are met:

a. No joint specific physical exam findings on exam but persisting pain/symptoms with failure of four-week trial of conservative therapy**

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within the past 6 months, OR worsening of symptoms during conservative treatment.

b. Positive site-specific orthopaedic exam findings, to include (but not limited to):

i. hip— hip clicking or locking or instability (suggesting labral tear), or positive anterior or posterior impingement sign (suggesting femoroacetabular impingement).
ii. knee— locking or clicking, anterior or posterior drawer sign, Lachman, McMurray or Apley test, abnormal varus or valgus stress, hemarthrosis on joint aspiration.
iii. ankle—positive stress x-rays or drawer sign or Thompson sign (suggesting Achilles tendon tear).

c. Marked joint swelling (or effusion seen on x-ray) continuing for more than 2 weeks after an injury WITH pain and limited range of motion on exam AND x-ray has been obtained and is negative or shows only effusion.

d. Joint instability on exam or recurrent joint dislocations

S. For any of the following diagnoses, known or suspected, provided that a 4-week trial of conservative therapy has not improved symptoms, or symptoms have worsened during conservative therapy:**

a. tarsal coalition
b. sinus tarsi syndrome
c. CRPS d. plantar fasciitis (after failure of at least 6 months of treatment, with at least 2 of the following: mechanical de-weighting, foot orthosis, night splints, taping or manual therapy) e. bursitis/tendinitis
f. ankle sprain (not high in anatomy)
g. Baker’s cyst h. sports hernia i. epicondylitis of the elbow (medial or lateral) j. adhesive capsulitis, and manipulation under anesthesia or arthroscopic lysis of adhesions is planned.

T. Pre-operative evaluation for surgery or procedure

U. Contrast-enhanced MRI of the MSK (musculoskeletal) system is medically necessary if ONE of the following are met:

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a. MRI arthrography (non-contrast images not required) b. inflammatory arthritis such as rheumatoid arthritis
c. suspected tumors or infection (soft tissue or bone/osteomyelitis), in which case both noncontrast and contrast images are medically necessary.

**For purposes of the medical guideline, a trial of conservative treatment is defined as a combination of both active and inactive components, directed at the area of interest during the current episode of pain or within the past six months. Inactive components include medications (such as analgesics, anti-inflammatory medications, muscle relaxants), rest, ice, or heat. Active modalities include either Physical Therapy, Chiropractic or osteopathic manipulations, or a physician assisted home exercise program.

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.

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. The following indications are considered not medically necessary for MRI:

a. sebaceous cysts
b. subcutaneous lipoma, unless surgery planned or malignant degeneration suspected.
c. ganglion, except as noted in Indications of Coverage (above) d. Serial MRI to assess healing or recovery from disease is considered not medically necessary, with rare exceptions (medical director review is needed).

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e. Repeating an MRI before 3 months after an initial MRI showing stress fracture/stress reaction.

C. The following indications are considered experimental, investigational, unproven:

a. MRI for evaluation of compartment syndrome is considered experimental, investigational, unproven (direct measurement of compartment pressures is standard of care).
b. Dynamic or positional MRI (to include weight-bearing or kinetic MRI). c. Magnetic resonance neurography for diagnosis of peripheral nerve disorders. d. Low field MRI for musculoskeletal conditions.

D. Pre-operative MRI for surgical planning using intraoperative navigation for joint arthroplasty is considered not medically necessary, as computer-assisted surgical navigation is deemed experimental, investigational, unproven.

E. For 3D Rendering of MRI, please refer to the WPS medical guideline, 3D rendering for MRI, CT, and Ultrasound.

Documentation Required:

Prior authorization is required for all upper and lower extremity 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 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.

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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 1/1/24, 7/1/24, 10/01/24, 09/01/25, 05/01/26 Medical Guideline Committee Approval 10/26/23, 02/23/24, 09/26/24, 03/27/25, Q1 2026 Reviewed

10/26/23, 02/23/24, 09/26/24, 03/27/25, Q1 2026 Revised 02/23/24
Developed 10/26/23

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Codes
Code Description

73218 Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast material(s)
73219 Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; with contrast material(s)
73220 Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences
73221 Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s)
73222 Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; with contrast material(s)
73223 Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences
73718 Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; without contrast material(s)
73719 Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; with contrast material(s)

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73720 Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences
73721 Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material
73722 Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; with contrast material(s)
73723 Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences
S8042 Low-field magnetic resonance imaging (MRI)

ASSOCIATED CODES A9573 Injection, Gadopiclenol, 1 ml
A9575 Injection, Gadoterate Meglumine, 0.1 ml
A9577 Injection, Gadobenate Dimegluine (Multihance), per ml
A9578 Injection, Gadobenate Dimegluine (Multihance Multipack), per ml
A9585
Injection, Gadobutrol 0.1 ml
Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml
Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml
Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml