Cardiovascular Magnetic Resonance (CMR) Page 1 of 11 No review or update is scheduled on this Medical Policy as it is unlikely that further published literature would change the policy position. If there are questions about coverage of this service, please contact Blue Cross and Blue Shield of Kansas customer service, your professional or institutional relations representative, or submit a predetermination request. Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Cardiovascular Magnetic Resonance (CMR) Professional Institutional Original Effective Date: August 4, 2005 Original Effective Date: July 1, 2006 Revision Date(s): February 27, 2006, Revision Date(s): May 2, 2007; May 2, 2007; November 1, 2007; November 1, 2007; January 1, 2010; January 1, 2010; February 15, 2013; February 15, 2013; December 11, 2013; December 11, 2013; April 15, 2014; April 15, 2014; July 15, 2014; June 10, 2015; July 15, 2014; June 10, 2015; June 8, 2016; June 8, 2016; October 1, 2016; October 1, 2016; May 10, 2017; May 10, 2017; April 25, 2018; April 25, 2018; October 1, 2018 October 1, 2018 Current Effective Date: July 15, 2014 Current Effective Date: July 15, 2014 Archived Date: July 3, 2019 Archived Date: July 3, 2019 State and Federal mandates and health plan member contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service. The BCBSKS Medical Policies contained herein are for informational purposes and apply only to members who have health insurance through BCBSKS or who are covered by a self-insured group plan administered by BCBSKS. Medical Policy for FEP members is subject to FEP medical policy which may differ from BCBSKS Medical Policy. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents of Blue Cross and Blue Shield of Kansas and are solely responsible for diagnosis, treatment and medical advice. If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan. Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Cardiovascular Magnetic Resonance (CMR) Page 2 of 11 No review or update is scheduled on this Medical Policy as it is unlikely that further published literature would change the policy position. If there are questions about coverage of this service, please contact Blue Cross and Blue Shield of Kansas customer service, your professional or institutional relations representative, or submit a predetermination request. DESCRIPTION Cardiovascular magnetic resonance (CMR) is established in clinical practice for the diagnosis and management of disorders of the cardiovascular system. CMR has several advantages over other imaging modalities: • Non-invasive • No ionizing radiation • No known clinical side effects • Soft tissue imaging is superior • No imaging artifact from bone • Equal clarity in any view: axial, sagittal, coronal, or oblique • Ability to acquire two, three, and four-dimensional data Disadvantages of CMR include: • Requires more patient cooperation • Longer imaging times • Incompatibility with various medical and life support devices • Attraction of ferromagnetic objects • Cost (When applied appropriately with state of the art MRI technology and expertise, initial test cost may be offset by a reduction in downstream utilization of other redundant imaging tests. CMR has the potential to provide a comprehensive examination in one setting at considerably less risk and cost to the patient.) POLICY A. Medically necessary indications for CMR include: 1. Congenital heart disease a. Assessment of shunt size b. Situs anomalies with complex congenital heart disease c. Anomalous pulmonary venous return, especially in complex anomalies and cor triatriatum d. Anomalous systemic venous return e. Systemic or pulmonary venous obstruction f. Ventricular Septal Defect (VSD) associated with complex anomalies g. Supracristal VSD h. Evaluation of right and left ventricular volumes, mass and function i. Pulmonary regurgitation j. Supravalvular aortic stenosis k. Post-operative follow-up of shunts l. Aortic (sinus Valsalva) aneurysm Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Cardiovascular Magnetic Resonance (CMR) Page 3 of 11 No review or update is scheduled on this Medical Policy as it is unlikely that further published literature would change the policy position. If there are questions about coverage of this service, please contact Blue Cross and Blue Shield of Kansas customer service, your professional or institutional relations representative, or submit a predetermination request. m. Aortic coarctation n. Vascular rings o. Aortopulmonary window p. Anomalous origin of coronary arteries q. Pulmonary atresia r. Central pulmonary stenosis s. Systemic to pulmonary collaterals 2. Acquired diseases of the vessels a. Diagnosis and follow-up of thoracic and abdominal aortic aneurysm including Marfan syndrome b. Diagnosis and follow-up of chronic aortic dissection c. Diagnosis of aortic intramural hemorrhage d. Diagnosis of penetrating ulcers of the aorta e. Pulmonary artery anatomy and flow f. Assessment of thoracic, abdominal and pelvic veins g. Assessment of renal arteries h. Assessment of iliac, femoral and lower leg arteries i. Assessment of thoracic great vessel origins j. Assessment of cervical carotid arteries k. Assessment of pulmonary veins including one in association with an electrophysiology ablation for atrial fibrillation 3. Coronary artery disease a. Assessment of global ventricular (left and right) function and mass b. Coronary anomalies c. Acute and chronic myocardial infarction - detection and assessment; myocardial viability 4. Pericardial disease, cardiac tumors, cardiomyopathies and cardiac transplants a. Detection and characterization of cardiac and pericardiac tumors b. Hypertrophic cardiomyopathy c. Dilated cardiomyopathy - differentiation from dysfunction related to coronary artery disease d. Arrhythmogenic right ventricular cardiomyopathy (dysplasia) e. Siderotic cardiomyopathy (in particular thalassemia) f. Restrictive cardiomyopathy 5. Valvular heart disease a. Cardiac chamber anatomy and function Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Cardiovascular Magnetic Resonance (CMR) Page 4 of 11 No review or update is scheduled on this Medical Policy as it is unlikely that further published literature would change the policy position. If there are questions about coverage of this service, please contact Blue Cross and Blue Shield of Kansas customer service, your professional or institutional relations representative, or submit a predetermination request. b. Quantification of regurgitation or stenosis B. Experimental / investigational indications: 1. CMR as a screening test 2. Coronary MRA for screening of coronary artery disease C. Subject to review for medical necessity: 1. CMR for indications that are not listed above 2. Duplication of services such as CT scan, radionuclide studies, ultrasound, and MRI CODING The following codes for treatment and procedures applicable to this policy are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non- coverage of these services as it applies to an individual member. CPT/HCPCS 75557 Cardiac magnetic resonance imaging for morphology and function without contrast material; 75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging 75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; 75563 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) ICD-10 Diagnoses A18.84 Tuberculosis of heart A52.00 Cardiovascular syphilis, unspecified A52.01 Syphilitic aneurysm of aorta A52.02 Syphilitic aortitis A52.03 Syphilitic endocarditis A52.04 Syphilitic cerebral arteritis A52.06 Other syphilitic heart involvement A52.09 Other cardiovascular syphilis C34.01 Malignant neoplasm of right main bronchus C34.02 Malignant neoplasm of left main bronchus Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Cardiovascular Magnetic Resonance (CMR) Page 5 of 11 No review or update is scheduled on this Medical Policy as it is unlikely that further published literature would change the policy position. If there are questions about coverage of this service, please contact Blue Cross and Blue Shield of Kansas customer service, your professional or institutional relations representative, or submit a predetermination request. C34.11 Malignant neoplasm of upper lobe, right bronchus or lung C34.12 Malignant neoplasm of upper