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

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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 or . 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 (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 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

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5. Isolated third cranial nerve palsy with pupillary involvement b. Follow up of known (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. or c. Known coarctation of the aorta or d. Loeys-Dietz syndrome or e. Spontaneous coronary artery

 *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.

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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 , 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 , 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 of brain or skull base. k. For suspected intracranial disease or in patients with recent signs/symptoms of 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 (dural sinus thrombosis, cerebral venous sinus thrombosis). n. MRV to distinguish between benign intracranial (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 velocity of greater than 200. r. Surgical planning for refractory trigeminal neuralgia

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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 or AV fistula).

e. For evaluation of pulsatile neck mass and/or pulsatile tinnitus following carotid : 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

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.

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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 , 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 requiring further evaluation

4. Chest:

a. For diagnosis, treatment planning, and post-operative follow-up of conditions of the thoracic aorta, heart or thoracic vasculature, when results are indeterminate, or when additional imaging is required for management decisions. These conditions may be congenital or acquired, and may include any of the following:

1. Aortic arch abnormalities, vascular rings, bicuspid aortic valve, or congenital abnormalities of the coronary arteries, pulmonary vasculature, or associated branch vessels, or congenital aortic abnormalities.

2. Coarctation of the thoracic aorta

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3. Pulmonary or artery anomalies

4. Suspected pulmonary arteriovenous malformation (AVM) or (AVF)

5. Congenital heart disease [for example, patent ductus arteriosus (PDA), truncus arteriosus, atrial or ventricular septal defects (ASD, VSD), patent foramen ovale (PFO)]

6. Coronary artery aneurysm

7. Thoracic or thoracoabdominal aneurysm or dissection (imaging above and below the diaphragm)

8. For preoperative evaluation of the pulmonary veins and left atrium for radiofrequency ablation treatment of atrial fibrillation.

9. For diagnosing a suspected or known pulmonary when computed angiography (CTA) is contraindicated.

10. For evaluation of signs or symptoms indicative of vascular insufficiency of the neck, chest, or arms, such as Takayasu’s arteritis or thoracic outlet syndrome.

11. For follow-up evaluation of new signs or symptoms indicative of progressive vascular stenosis after a previous angiogram or MRA.

12. For treatment planning for evaluation for known or suspected vascular disease, (such as aneurysm, dissection, or stenosis/occlusion) and patient has not had a catheter angiogram or computed tomography angiography (CTA) within the last month.

13. For postoperative evaluation for known vascular disease with physical evidence of a re-bleed or re-stenosis.

14. For evaluation of suspicious mass and CTA is contraindicated.

15. For evaluation of a mediastinal or thoracic mass with suspected vascular involvement.

16. For evaluation of primary or secondary or congenital heart disease with pulmonary hypertension.

17. For evaluation of suspected pulmonary sequestration.

18. For evaluation of central or superior vena cava syndrome.

19. For subclavian steal syndrome documented (or inconclusive) with ultrasound.

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20. For screening of individual with a first degree relative (parent, sibling, or child) with thoracic or dissection or a vascular high risk mutation.

21. Screening of second degree relative for aortic aneurysm or dissection when the individual has at least two first or second degree relatives with documented thoracic aortic dilatation, aneurysm, or dissection.

22. For post-operative/post-procedural evaluation: Follow-up MRA will be deemed medically necessary to evaluate post-operative complications, as well as for open surgical repair, at 5 year intervals. For endovascular thoracic aortic repair, initial reevaluation at 1 month, and if abnormal, or for dissection, at 6 months post repair, then annually for 5 years.

23. For evaluation of aortic and pulmonary arterial and branch vessel vasculopathy in individuals with a known or suspected vasulopathy and a known or suspected syndrome (e.g., Marfan syndrome, Williams syndrome, mid aortic syndrome, or neurofibromatosis type 1).

24. For evaluation of sickle cell -related vascular abnormalities

25. For vascular neoplasm operative planning (regardless of location of the neoplasm)

26. For evaluation of vascular status following extracorporeal membrane oxygenation (ECMO) treatment.

27. For follow up six months after initial finding of thoracic aorta dilation, to assess the rate of growth.

28. For follow up annually of thoracic aorta that is enlarged but not greater than 4.5 cm in diameter.

29. For follow up twice a year of enlarged aortic root greater than or equal to 4.5 cm or with rate of growth greater than or equal to 0.5 cm per year, or with family history of in a first degree relative.

30. For evaluation of the ascending aorta in individuals with connective tissue disease (known or suspected) or for individuals with genetic conditions that place them at higher risk for aortic aneurysm or dissection (e.g., Loeys-Dietz syndromes Marfan syndrome, Ehlers Danlos). MRA considered medically necessary at the following times: At time of diagnosis, at 6 months after the diagnosis to assess rate of growth, then annually. If the diameter is greater than or equal to 4.5 cm or expanding greater than or equal to 0.5 cm per year, evaluation twice a year is considered medically necessary.

31. For evaluation of individuals with Turner’s syndrome to assess for bicuspid aortic valve, dilation of the ascending or thoracic aorta, or coarctation of the aorta. Follow up imaging every 5 to 10 years is appropriate if the initial imaging was normal and the individual does not have additional risk factors for dissection. If an abnormality was found, annual imaging is considered appropriate.

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32. For screening of individuals with first degree relative with a bicuspid aortic valve.

33. For re-evaluation of individuals with history of aortic dissection or a known dilation of the ascending aorta if they have a change in cardiac exam, change in clinical status, or when medical management may be altered by findings.

34. For re-evaluation twice a year in individuals with bicuspid aortic valve who have one of the following:

aa. Diameter of aorta is greater than or equal to 4.5 cm

bb. First degree relative with history of aortic dissection

cc. Annual rate of growth of the diameter of the aorta of greater than or equal to 0.5 cm

35. For follow up after treatment of acute dissection at 1 month, then at 6 months, then annually.

36. For annual evaluation after medical treatment of chronic dissection.

37. For follow up (baseline after surgery, then annually) after an aortic root repair or after aortic valve repair with repair of aortic arch or root.

5. Abdomen and / or Pelvis:

a. To evaluate for when one of the following is documented:

1. Refractory, uncontrolled hypertension (HTN) despite optimal doses of three (3) or more medications

2. Onset of HTN in patient younger than 30 years old, with no other risk factors and no other family history of HTN

3. Onset HTN at age greater than 50 years old

4. Unexplained renal failure or insufficiency (only if ultrasound is inconclusive)

5. Hypertension with bruit heard over the renal artery

6. Acute decline in renal function after initiating medication with either angiotensin converting enzyme inhibitor OR angiotensin receptor blocker

7. Malignant hypertension

8. Diagnosis of either neurofibromatosis, tuberous sclerosis, or Williams’ syndrome, with high risk of vascular disease

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9. Significant hypertension (diastolic pressure >110) in an adult less than 35 years old b. For evaluation of aortic aneurysm, to include preoperative/pre-procedural evaluation for abdominal aortic aneurysm (AAA) repair, whether surgical or endovascular. The frequency of follow-up of AAA is dependent upon size, rate of growth, and associated comorbidities. c. For evaluation of known or suspected abdominal large artery or vein disease (aorta, IVC, mesenteric, celiac, renal, splenic , iliac) d. For evaluation of known or suspected visceral artery aneurysm e. Follow up of iliac artery aneurysm, with Doppler ultrasound that is either inconclusive or indeterminate: Every three years for iliac artery aneurysm 2.0 to 2.9 cm. Six month follow up if aneurysm is between 3.0-3.5 cm and, if stable, followed yearly. If aneurysm is greater than 3.5cm, less than six month follow up (e.g. considering intervention). f. Acute rise in blood pressure in a person with previously stable blood pressures. g. Flash pulmonary without identifiable causes. h. Malignant hypertension. i. To evaluate for suspected acute or ischemic colitis when CTA (computed tomography angiography) is contraindicated, or the results of CTA are inconclusive. j. For suspected chronic mesenteric ischemia k. To evaluate suspected renal vein thrombosis in patients with known renal mass or other cause. l. To further evaluate hepatic vascular abnormalities (e.g. aneurysm, venous thrombosis, stenosis, or obstruction in the portal or hepatic veins (portal venous thrombosis or Budd-Chiari syndrome) or systemic veins, such as inferior vena cava, renal veins, or iliac veins after indeterminate or equivocal ultrasound, to enhance or clarify ultrasound finding. This includes post-operative complications of renal transplant allograft, such as inferior vena cava (IVC) thrombosis. m. To evaluate hepatic vasculature prior to transjugular intrahepatic portosystemic shunt (TIPS) procedure after indeterminate or equivocal ultrasound. n. To evaluate transjugular intrahepatic portosystemic shunt when ultrasound suggests potential TIPS complication. o. For evaluation, surgical or treatment planning of abdominal–pelvic vascular injury (e.g. pelvic trauma).

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p. To assess for arterial stenosis or occlusion in the aorta, pelvic vessels and lower extremity vessels in patients with signs or symptoms of peripheral vascular disease / and ultrasound ankle brachial index (ABI) of less than 0.9. This is commonly performed as MRA abdomen, pelvis, and lower extremities.

q. Suspected retroperitoneal or to determine the potential source of retroperitoneal hemorrhage, when CTA is contraindicated or inconclusive.

r. For evaluation of known or suspected vascular disease. Any of the following:

1. Arterial entrapment syndrome.

2. Large vessel diseases, e.g., aneurysm, dissection, arteriovenous malformations (AVMs), and fistulas, intramural hematoma, and vasculitis.

3. Inferior vena cava (IVC) , pelvic vein thrombosis, or , or for diffuse unexplained lower extremity edema with ultrasound being either negative or inconclusive.

4. Vascular invasion or displacement by tumor.

5. Venous thrombosis if previous studies have not resulted in a clear diagnosis.

6. Suspected pelvic vascular disease such as pelvic congestion syndrome when findings on ultrasound are indeterminate

7. For suspected May-Thurner syndrome

8. In pregnant women with suspected (MRV of pelvis)

9. For evaluation of patients with known fibromuscular dysplasia, Vascular Ehlers- Danlos syndrome or Marfan’s syndrome (one time study to be approved). For Loeys-Dietz, MRA is medically necessary every two years. s. Pre-operative evaluation for any of the following:

1. Evaluation of aortoiliac occlusion, stenosis or peripheral vascular disease of the leg and ankle brachial index (ABI) is less than 0.9.

2. Pre-transplant evaluation of the liver and/or kidney, to include both donor and recipient evaluation.

3. Evaluation of interventional vascular procedures for luminal patency versus restenosis due to conditions such as , thromboembolism, and intimal hyperplasia.

4. Evaluation of inferior epigastric arteries prior to breast reconstructive surgery.

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5. Prior to uterine artery embolization for uterine fibroids.

t. Post-operative evaluation for any of the following:

1. Evaluation of endovascular or interventional vascular procedures for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia or graft leakage. Postoperative surveillance after endovascular repair of abdominal aortic aneurysm (AAA) in an asymptomatic patient may be considered medically necessary between one and three months post-operatively, then at six month intervals for one year, then annually. More frequent imaging may be required in individuals who are symptomatic after endovascular aneurysm repair.

2. Evaluation of post-operative complications, e.g. , related to surgical bypass grafts, vascular and -grafts

3. Evaluation of post-operative complications of renal transplant allograft

4. Follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention or surgery. Documentation must include clear indication of why additional imaging is needed for the type and area(s) requested.

u. To evaluate abdominal and/or pelvic extent of aortic dissection.

6. Spinal Canal:

a. Cervical spine fracture, disc herniation, venous thrombosis, or infection when there is concern for vascular injury or compromise.

b. Known or suspected vertebral artery injury with concern for vascular compromise of the spinal canal and its contents.

c. Known or suspected spinal arteriovenous malformation (AVM) or arteriovenous fistula (AVF), to include myelopathy with suspected vascular compromise.

d. Preoperative evaluation in which localization of the spinal arteries is essential.

e. Myelopathy with suspected spinal cord arterial or venous compromise.

f. Follow up study after intervention or surgery to the spine or associated structures. Documentation must include clear indication of why additional imaging is needed for the type and area(s) requested.

7. Extremities:

a. Upper Extremity:

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1. For evaluation of suspected or known upper extremity arterial compromise or vascular abnormality of upper extremity (e.g., arteriovenous malformation, fistula, fibromuscular dysplasia, aneurysm, vasculitis, vascular compression by adjacent masses,subclavian steal syndrome, thoracic outlet syndrome, embolism or thrombosis, intramural hematoma, Raynaud’s Syndrome, Buerger disease or other vasculopathy). With the presence of ischemic ulceration of the hand, with acute perfusion loss, or with imminent loss of a digit, a preceding arterial Doppler is not required. Otherwise, there must be a prior abnormal arterial Doppler and documentation that the MRA results will alter management.

2. For evaluation of suspected venous thrombosis of central veins and/or subclavian veins, or if there is documentation that management of known venous thrombosis of arm veins may be altered by MRV results.

3. For pre-operative evaluation of known upper extremity vascular disease or condition.

4. To evaluate suspected traumatic injury to the vasculature of upper extremity when site and extent of injury are not obvious or there are clinical findings suggestive of arterial injury.

5. Post-surgical or post-vascular interventional procedure to assess luminal patency/restenosis or complication such as pseudoaneurysms.

6. Evaluation of surgically created dialysis fistulas and grafts, and Doppler Ultrasound results are inconclusive. b. Lower Extremity:

1. For diagnosis and surgical planning in the treatment of peripheral vascular disease of the lower extremity including arterial insufficiency, ischemia, claudication, or ulceration felt to be of vascular etiology. MRA is considered medically necessary for evaluating suspected peripheral vascular disease if one of the following is present: a. critical limb ischemia with either ischemic rest pain or gangrene/tissue loss b. claudication with ankle brachial index (ABI) less than 0.9 in one of the extremities, or abnormal arterial Doppler, or the ultrasound is indeterminate c. lower extremity ulcer(s), felt to be of vascular etiology, with ultrasound being abnormal or indeterminate

2. For post-operative/ post procedure evaluation for luminal patency vs re-stenosis, or for complications such as pseudoaneurysm related to bypass grafts, vascular stents, and stent-grafts.

3. To evaluate suspected traumatic vascular injury in the lower extremity when site and extent of injury are not obvious or there are clinical findings suggestive of arterial injury.

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4. MRV for evaluation of suspected venous thrombosis or venous compromise, only if extremity ultrasound has been performed and is indeterminate, inconclusive, or abnormal and a positive result would change management.

5. For pre-operative evaluation for a planned lower extremity surgery or procedure.

6. For clinical suspicion of lower extremity vascular disease (AVM, vasculitis, aneurysm, tumor invasion, popliteal entrapment syndrome) when ultrasound and/or CT is abnormal or indeterminate

B. MRA is considered medically necessary when CTA or catheter angiography is clinically indicated, however is contraindicated due to any of the following:

1. Allergy to 2. Renal insufficiency or failure 3. Pregnancy

Limitations of Coverage:

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 denied as experimental or investigative.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, it will be denied as not medically necessary.

D. MRA Head is considered not medically necessary in any of the following situations:

1. For evaluation of migraine or recurrent headache when there has been a normal neurological evaluation.

2. Chronic headache due to suspected sinusitis.

3. Chronic headache or evaluating/monitoring a history of headache in the absence of documented clinical concern for headache etiologies listed in Indications of Coverage A.1.a.

4. For evaluation of trigeminal neuralgia, unless if used for surgical planning in refractory trigeminal neuralgia.

E. MRA Neck is considered not medically necessary when performed for routine follow up after or percutaneous intervention (such as, carotid angioplasty).

F. When both catheter angiography and MRA, or CTA and MRA are performed to evaluate the same condition/anatomical region, the second test is considered not medically necessary, unless there is documentation of at least one of the following:

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1. A significant change in symptoms or condition warrants the second test.

2. Previous diagnostic testing (for example, imaging and/or ultrasound) is contradictory or inconclusive.

3. Inflow and outflow blood vessels were not identified on the first exam.

G. MRV of the extremities (lower and upper) is considered not medically necessary without documentation of an inconclusive or indeterminate venous ultrasound, or documentation that the MRV is expected to provide further clinical information not provided by the ultrasound.

H. Repeat MRA/MRV: If not specified in the indications above, repeat MRA is considered not medically necessary unless there is documentation of 1 or more of the following:

1. Change in clinical status (e.g., worsening symptoms or new associated symptoms).

2. Documentation of how interval reassessment may impact the treatment plan.

3. Documentation from the provider regarding rationale for repeated testing with documentation of the medical need for the type and location of additional testing.

Documentation Required:

• Office notes from referring/ordering physician

• Order for the MRA (a comment in the referring/ordering physician’s office notes is sufficient)

• reports

Medical Policy Review History:

Implemented 01/01/2016, 01/01/17, 04/01/18, 01/01/19, 04/01/19, 04/01/2020, 01/01/21 Medical Policy 06/13/14, 09/11/15, 09/16/16, 12/09/16, 12/01/17, 09/21/18, 12/14/18, Committee 11/22/19, 12/11/20 Approval Reviewed 06/13/14, 09/11/15, 09/16/16, 12/09/16, 12/01/17, 09/21/18, 12/14/18, 11/22/19, 12/11 /20 Developed

 Note: For review/revision history prior to 2014 see previous Medical Policy or Coverage Policy Bulletin

Approved by the Medical Director

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Disclaimer:

This policy 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 not provide coverage for all services listed in this policy. 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 policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical policies 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 Health to assist in administering health benefits. This medical policy and MCG Health 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 [email protected].

The information contained in this document is proprietary to Wisconsin Physicians Service Insurance Corporation (WPS) and is confidential. This document shall not be disclosed, duplicated or used in any manner, in whole or in part, for any other purpose without prior written consent of WPS. Copying or distributing this material without permission is strictly prohibited.

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