MRI (Magnetic Resonance Imaging) of the Chest Form

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MRI (Magnetic Resonance Imaging) of the Chest Medical Guideline Service: MRI Chest

PUM 250-0054-1812

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

Description:

Chest magnetic resonance imaging (MRI) is a non-invasive imaging technique that uses a strong magnetic field and radio waves to create detailed images of the chest. MRI may be used instead of computed tomography (CT) in patients with allergies to radiographic contrast or with impaired renal function. Also, to decrease radiation exposure, Chest MRI may be used rather than CT when repeated imaging is expected (i.e., surveillance).
Indications of Coverage: A Chest MRI is considered medically necessary when at least ONE or more of the following criteria are met:

A. Evaluation of suspected or known cardiac lesions per CMR (cardiac magnetic resonance) guideline.

B. Evaluation of suspected or known thoracic masses with 1 or more of the following:

a. X-ray or ultrasound are non-diagnostic AND lesion is not a parenchymal pulmonary nodule (CT chest is typically the study of choice for parenchymal pulmonary nodules, whether solitary or multiple)

b. Patient has myasthenia gravis and requires thymoma screening

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c. Congenital thoracic malformation seen on other imaging and further information needed to determine the need for biopsy and/or surgery

d. Staging of lung cancer AND CT chest is not available, contraindicated, or results indeterminate AND MRI chest with and without IV contrast is requested.

C. Evaluation of suspected of known chest wall pathology with 1 or more of the following:

a. Congenital malformation of chest, diaphragm, lungs, mediastinum, or great vessels, known or suspected, when further information is needed to determine the need for biopsy and/or surgery.

b. Fetal chest or lung anomaly, known or suspected, AND ultrasound results are abnormal or indeterminate.

c. Chest wall pain AND chest x-ray or rib films are indeterminate AND 1 or more of the following are known or suspected:

i. Malignancy ii. Infectious or inflammatory condition iii. History of prior chest intervention

d. Signs and symptoms of infection with concern for chest wall involvement, such as 1 or more of the following:

i. fever
ii. elevated inflammatory markers
iii. known infection at other sites

e. For known or suspected injuries to costochondral cartilage or sternoclavicular joint or manubriosternal joint, ONLY if radiographs and CT are indeterminate. For suspected pectoralis injuries, MRI is the procedure of choice

f. Evaluation of chest wall mass when CT or plain radiographs are indeterminate, or when needed to plan biopsy/treatment.

D. Evaluation of suspected or known lung disease for 1 or more of the following:

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a. Prior to anticipated lung resection/lung reduction surgery to predict postoperative pulmonary function reserve AND results of nuclear medicine lung perfusion scan indeterminate AND CT scan contraindicated or not available.

b. Congenital heart disease with pulmonary hypertension

c. Pulmonary sequestration

E. Evaluation of suspected or known brachial plexus disorders for 1 or more of the following (a-d):

a. Mass involving brachial plexus

b. Known or suspected neurogenic thoracic outlet syndrome, and 1 or more of the following:

i. Cervical or anomalous first rib ii. Positive Tinel sign over the brachial plexus iii. Scalene muscle hypertrophy iv. Pain, fatigue, or paresthesia worse with overhead use of arm v. Symptoms relieved by anterior scalene muscle block vi. Thenar or hypothenar atrophy vii. If the mechanism of an injury is suggestive viii. Electromyography/Nerve Conduction Velocity (EMG/NCV) studies are suggestive

c. Neuropathy, suspected, as indicated by 1 or more of the following:

i. Chronic inflammatory demyelinating polyneuropathy ii. Hereditary hypertrophic motor and sensory neuropathies iii. Inflammatory pseudotumor iv. Multifocal motor neuropathy

d. Traumatic injury

F. Cancer or neoplasm evaluation, staging, or surveillance needed consistent with NCCN guidelines.

G. For surgical planning prior to debridement or interventional procedures for thoracic infection.

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H. For disorders of the lung parenchyma or tracheobronchial tree or pleura, in which CT is contraindicated, or has been completed and results are indeterminate or require further characterization.

I. 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. 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. For evaluation of pulmonary nodules/masses or parenchymal disorders (such as pulmonary fibrosis) MRI is considered not medically necessary, unless results of the CT are indeterminate, or require further characterization.

E. For evaluation of suspected vascular outlet syndrome, MRI is considered not medically necessary as CTA or MRA would be the preferred study.

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Documentation Required:

Prior authorization is required for all chest 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 patient’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. 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, 12/01/24, 09/01/25, 05/01/26 Medical Guideline Committee Approval 10/26/23, 11/21/24, 03/27/25, Q1 2026 Reviewed

10/26/23, 11/21/24, 03/27/25, Q1 2026 Developed 10/26/23, 11/21/24

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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

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 sequences
C9791 Magnetic resonance imaging with inhaled hyperpolarized xenon-129 contrast agent, chest, including preparation and administration of agent

ASSOCIATED CODES A9610 Xenon XE-129 hyperpolarized gas, diagnostic, per study dose