CMS Magnetic Resonance Angiography (MRA) Form

Summary Of Evidence

N/A

Analysis of Evidence

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Magnetic resonance angiography (MRA) is a non-invasive diagnostic test that is an application of magnetic resonance imaging (MRI). By analyzing the amount of energy released from tissues exposed to a strong magnetic field, MRA provides images of normal and diseased blood vessels as well as visualization and quantification of blood flow through these vessels.

Please refer to the National Coverage Determination for MRI and MRA documented in CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2 Magnetic Resonance Imaging (MRI) for coverage details.


COVERED INDICATIONS

I. HEAD AND NECK

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.A.2 and 220.2.B.2 for coverage details and guidelines on the use of MRA of the head and neck.

MRA is appropriately used to verify the presence of a condition, suspected because of findings from another test (usually an imaging study). For example, a patient who presents with a transient ischemic attack (TIA) should not undergo MRA simply because he might have a lesion which is amenable to surgery. However, if that patient has a carotid bruit and is found by Doppler study to have carotid stenosis, an MRA may be appropriate to evaluate the stenotic section of artery for surgical intervention. Please note that the anticipated surgery may be a percutaneous procedure such as carotid angioplasty with stent insertion.

Another patient may present with a headache; it is not appropriate to proceed directly to MRA to rule out the possibility of an intracranial aneurysm. However, if that patient was found to have a clinically significant amount of blood in the cerebrospinal fluid, or the patient demonstrated signs and symptoms strongly suggesting an unruptured intracranial aneurysm, an MRA (or cerebral angiogram) may be appropriate.

An MRA is not considered medically reasonable and necessary for screening asymptomatic patients for intracranial aneurysms.

II. PERIPHERAL ARTERIES OF LOWER EXTREMITIES

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.B.2.b for coverage details and guidelines on the use of MRA in the peripheral arteries of the lower extremities.

III. ABDOMEN AND PELVIS

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.B.2.c for coverage details and guidelines on the use of MRA in the pre-operative evaluation of patients undergoing elective abdominal aortic aneurysm (AAA) repair and imaging of the renal arteries and aortoiliac arteries in the absence of AAA or aortic dissection.

An MRA of the abdomen for evaluation of possible renal artery stenosis would not be considered medically reasonable and necessary without some evidence consistent with renovascular hypertension. Such evidence might include:

• a history of early or late onset of hypertension, hypertension refractory to medication, or worsening renal function;
• the presence of a renal artery bruit;
• laboratory tests (elevated serum renins, increasing creatinine); or
• other radiologic tests (ultrasound, captopril scintigraphy, or other imaging showing small kidney or unequal kidney sizes).

IV. CHEST

Diagnosis of Pulmonary Embolism

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.B.2.d.i for coverage details and guidelines on the use of MRA in the diagnosis of pulmonary embolism.

Evaluation of Thoracic Aortic Dissection and Aneurysm

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.B.2.d.ii for coverage details and guidelines on the evaluation of thoracic aortic dissection and aneurysm.

NOTE: This LCD does not address cardiac magnetic resonance imaging.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.