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(MRA) and Magnetic Resonance Venography (MRV) Medical Policy

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(MRA) and Magnetic Resonance Venography (MRV) Medical Policy Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV) Medical Policy The content of this document is used by plans that do not utilize NIA review. Service: Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV) PUM 250-0027-1712 Medical Policy Committee Approval 12/11/2020 Effective Date 01/01/2021 Prior Authorization Needed Yes Description: Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV) use Magnetic resonance imaging (MRI) technology to produce detailed 2-dimensional or 3- dimensional images of the vascular system and may be tailored to assess arteries or veins. It is often used for vascular conditions where other types of imaging are considered inferior or contraindicated, and to decrease risk of cumulative radiation exposure and often instead of invasive procedures. Indications of Coverage: A. MRA/MRV is considered medically necessary for the anatomical regions listed below when the specific indications or symptoms described are documented: 1. Head/Brain: a. Suspected intracranial aneurysm (ICA) or arteriovenous malformation (AVM). Any of the following: 1. Acute severe headache, severe exertional headache, or sudden onset of explosive headache, in individuals with signs / symptoms highly suggestive of a leaking/ruptured internal carotid artery or arteriovenous malformation. 2. Known subarachnoid hemorrhage or diagnosis of spontaneous intracerebral hemorrhage with concern for underlying vascular abnormality. 3. Suspected arteriovenous malformation (AVM) or dural AV fistula in an individual with prior indeterminate imaging study 4. Thunderclap headache with question of underlying vascular abnormality AND prior negative workup to include EITHER i. negative brain MRI, OR ii. Negative brain CT and negative lumbar puncture Page 1 of 15 5. Isolated third cranial nerve palsy with pupillary involvement b. Follow up of known intracranial aneurysm (ICA). MRA is considered medically necessary for any of the following: 1. To evaluate a known non-ruptured intracranial aneurysm. A follow-up study may be needed to help evaluate an individual’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) required. 2. To follow up known ICA with persistent symptoms (e.g. ominous headache, focal neurologic findings, change in mental status, seizures). 3. To evaluate an aneurysm that is clinically or radiographically unstable. c. To screen for possible ICA in a patient who is at higher risk, as indicated by having one or more of the following: 1. History of ICA in a first degree relative (mother, father, sibling, child)* 2. Personal history of: a. Autosomal dominant polycystic kidney disease (after age 30) or b. Fibromuscular dysplasia or c. Known coarctation of the aorta or d. Loeys-Dietz syndrome or e. Spontaneous coronary artery dissection *Repeat study may be approved every 5 years (with or without new symptoms) if criteria for first degree family history is met. d. Follow-up of known arteriovenous malformation (AVM). Any of the following: 1. A follow-up study may be needed to help evaluate an individual’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested. 2. Follow up of known AVM with persistent symptoms (e.g. ominous headache, focal neurologic findings, change in mental status, seizures). 3. To evaluate an AVM that is clinically or radiographically unstable. Page 2 of 15 e. To evaluate known or suspected vertebrobasilar insufficiency (VBI). Symptoms suggestive of VBI may include temporary or permanent binocular vision loss, double vision, positional vertigo, irregularities in speech (slurred/slowed/limited), difficulties swallowing, loss of co-ordination, and confusion. f. To evaluate pulsatile tinnitus in patients with symptoms suggestive of a vascular etiology. g. For evaluation of known vasculitis, cerebral vasoconstriction syndrome, or Moyamoya disease. h. For evaluation of suspected CNS vasculitis when autoimmune antibodies are present or when abnormal lab results such as elevated C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) suggest acute inflammation, vasoconstriction syndrome, or Moyamoya disease. CNS vasculitis with known underlying systemic disease and neurologic signs/symptoms. Also to evaluate for suspected primary CNS vasculitis with presence of neurologic signs/symptoms, and completion of testing for inflammatory/infectious etiologies. i. Preoperative planning for delineation of vascular supply of vascular neoplasm. j. Preoperative planning or confirmation of diagnosis for vascular malformation of brain or skull base. k. For suspected intracranial disease or stenosis in patients with recent signs/symptoms of stroke or transient ischemic attack (TIA). May be performed in conjunction with MRA neck. l. For documented intraparenchymal hemorrhage (non-traumatic) with clinical concern for underlying vascular abnormality. m. MRV to evaluate known or suspected venous thrombosis (dural sinus thrombosis, cerebral venous sinus thrombosis). n. MRV to distinguish between benign intracranial hypertension (pseudotumor cerebri) and dural sinus thrombosis. o. For evaluation of acute, new or fluctuating neurologic symptoms or deficits such as sensory deficits, limb weakness, speech difficulties, lack of coordination or mental status changes. p. For evaluation of neurological findings in sickle cell disease in patients over age 16. q. For evaluation of stroke risk in individual with sickle cell disease with a transcranial Doppler velocity of greater than 200. r. Surgical planning for refractory trigeminal neuralgia Page 3 of 15 s. For further evaluation of an equivocal vascular abnormality seen on prior imaging of the brain. 2. Neck: a. For evaluation of carotid stenosis or occlusion in a symptomatic individual after an abnormal Doppler ultrasound showing one of the following: 1) Stenosis (equal to or greater than 50%) of the internal carotid artery or the common carotid artery 2) Reversal of flow in the carotid or vertebral artery 3) An inconclusive or technically inadequate study b. For evaluation of carotid stenosis or occlusion in an asymptomatic individual after an abnormal Doppler ultrasound showing one of the following: 1) Stenosis (equal to or greater than 70%) of the internal carotid artery or the common carotid artery 2) Reversal of flow in the carotid or vertebral artery 3) An inconclusive or technically inadequate study c. For evaluation of an individual with closed head injury, penetrating neck injury, or blunt head or neck trauma for suspected carotid or vertebral artery dissection or traumatic arterial injury or with suspected spontaneous arterial dissection. d. For evaluation of carotid body tumors, or other paragangliomas or other pulsatile mass (such as pseudoaneurysm or AV fistula). e. For evaluation of pulsatile neck mass and/or pulsatile tinnitus following carotid endarterectomy: Documentation requires a medical reason clearly indicating why the MRA, rather than ultrasound, is required. f. Suspected carotid or vertebral aneurysm, dissection, thromboembolism, pseudoaneurysm, vascular malformation/fistula or congenital anomaly of carotid or vertebrobasilar circulation. g. For evaluation of new onset stroke or transient ischemic attack (TIA). h. For evaluation of suspected giant cell arteritis i. For evaluation of neck vessels for Takayasu’s arteritis, provided Takayasu’s arteritis has been documented in other vessesls. j. For evaluation of subclavian steal syndrome with positive or inconclusive ultrasound results, or when MRA is necessary for interventional planning of subclavian steal syndrome. k. Post-operative or post-procedural evaluation, provided documentation of medical necessity is submitted. Page 4 of 15 l. Screening for aneurysm in patient with known fibromuscular dysplasia or spontaneous coronary artery dissection. 3. Combined Neck MRA and Head/Brain MRA studies: a. For evaluation of patients who have had a recent stroke or transient ischemic attack (TIA). b. For known or suspected vertebral basilar insufficiency with symptoms such as vision changes, vertigo, or abnormal speech. c. For evaluation of suspected carotid or vertebral artery dissection or arterial injury, due to head or neck trauma, or with suspected spontaneous dissection due to arterial wall weakness. d. For evaluation of pulsatile tinnitus. e. For evaluation of carotid stenosis or occlusion in a symptomatic individual, who is a candidate for surgery or angioplasty, after an abnormal Doppler ultrasound showing one of the following: 1) Stenosis (equal to or greater than 50%) of the internal carotid artery or the common carotid artery 2) Reversal of flow in the carotid or vertebral artery 3) An inconclusive or technically inadequate study f. For evaluation of carotid stenosis or occlusion in an asymptomatic individual, who is a candidate for surgery or angioplasty, after an abnormal Doppler ultrasound showing one of the following: 1) Stenosis (equal to or greater than 70%) of the internal carotid artery or the common carotid artery 2) Reversal of flow in the carotid or vertebral artery 3) An inconclusive or technically inadequate study g. For evaluation of Horner’s syndrome (miosis, ptosis, anhidrosis) or known extracranial vascular disease requiring further evaluation 4. Chest: a. For
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