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Defines Aetna's medical necessity criteria for MRI of the cardiovascular system (cardiac MRI), lists covered and not-covered CPT/HCPCS/ICD-10 codes, notes investigational procedures, and provides background/evidence. Applies to diagnostic cardiac/cardiovascular MRI studies when selection criteria are met.
No material clinical/coverage changes in this update.
This policy (Aetna Clinical Policy Bulletin Number: 0520) defines Aetna's medical necessity criteria and scope for Magnetic Resonance Imaging of the Cardiovascular System (Cardiac MRI / CMR). It applies to diagnostic cardiac/cardiovascular MRI studies when selection criteria are met and lists covered and not-covered CPT, HCPCS and ICD-10 codes. Policy status: CURRENT. Policy effective date: 2001-01-21; Last review date: 2023-08-01; Next review date: 2024-05-23.
| 75557 | Cardiac magnetic resonance imaging for morphology and function without contrast material. |
| 75559 | Cardiac magnetic resonance imaging for morphology and function 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 | with stress imaging. |
| 75565 | Cardiac magnetic resonance imaging for velocity flow mapping. |
| 71250-71270 | Computed tomography, thorax. |
| 71550-71552 | Magnetic resonance imaging, chest. |
| 76604 | Ultrasound, chest (includes mediastinum), real time with image documentation. |
| 77046-77047 | Magnetic resonance imaging, breast, without contrast material. |
| 78414-78499 | Nuclear medicine, cardiovascular system imaging. |
| 93303-93355 | Echocardiography. |
| A9576 | Injection, gadoteridol (ProHance multipack), per ml. |
| A9577 | Injection, gadobenate dimeglumine (MultiHance), per ml. |
| A9578 | Injection, gadobenate dimeglumine (MultiHance multipack), per ml. |
| A9579 | Injection, gadolinium based magnetic resonance contrast agent, not otherwise specified, per ml. |
| C9762 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging. |
| C9763 | with stress imaging. |
| Q0138 | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use). |
| Q0139 | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis). |
| J0151 | Injection, adenosine for diagnostic use, 1 mg. |
| Q2049 | Injection, doxorubicin HCl, liposomal, imported Lipodox, 10 mg. |
| Q2050 | Injection, doxorubicin HCl, liposomal, not otherwise specified, 10 mg. |
| A18.89 | Tuberculosis of other sites [myocardium]. |
| A36.81 | Diphtheritic cardiomyopathy. |
| A39.52 | Meningococcal myocarditis. |
| A52.00-A52.09 | Cardiovascular and cerebrovascular syphilis. |
| B33.22 | Viral myocarditis. |
| B58.81 | Toxoplasma myocarditis. |
| C34.00-C38.8 | Malignant neoplasm of bronchus and lung, thymus, heart, mediastinum and pleura. |
| C45.0,C45.2 | Mesothelioma of pleura and pericardium. |
| C47.3,C49.3 | Malignant neoplasm of peripheral nerves of thorax and connective and soft tissue of thorax. |
| C78.00-C78.2 | Secondary malignant neoplasm of lung, mediastinum and pleura. |
| I74.3 | Embolism and thrombosis of arteries of the lower extremities. |
| I75.021-I75.029 | Atheroembolism of lower extremity. |
| T86.20-T86.23 | Complications of heart transplant. |
| Z13.6 | Encounter for screening for cardiovascular disorders [routine without signs or symptoms of disease]. |
| Z94.1 | Heart transplant status. |
Justify multiple imaging studies
When multiple diagnostic imaging tests are performed, the physician must document the specific necessary information to be gained from the additional test(s) that the initial test did not provide for MRI to be considered medically necessary.
Medical review for duplicative services
Requests showing evidence of duplicative services (CT, radionuclide, ultrasound, sonogram, MRI, etc.) are subject to medical review for an evaluation of the medical necessity of the MRI; there must be a compelling reason and documentation is required for multiple procedures.
Use CMRI-derived quantitative metrics for decision support
CMR-derived measures (for example, regurgitant fraction, left ventricular volumes, extracellular volume [ECV], and right ventricular ejection fraction) can provide diagnostic and prognostic information that may inform treatment decisions, such as identifying patients for aortic valve intervention or characterizing amyloid burden.
Consider CMRI sequences for thrombus detection
Delayed-enhancement CMR (DE-CMR) demonstrated the highest sensitivity and specificity for left atrial/left atrial appendage thrombus detection compared with cine-CMR and contrast-enhanced MRA; consider DE-CMR when high diagnostic accuracy is required.
Consider CMRI for pediatric PH evaluation and follow-up
The European pediatric consensus (endorsed by ISHLT and DGPK) recommends cardiac MRI, without anesthesia/sedation when possible, for children with suspected or confirmed pulmonary hypertension as part of diagnostic evaluation and during follow-up to assess changes in ventricular function and chamber dimensions (Class I; Level B).
Consideration of CMR metrics for HFpEF prognostication
Multi-parametric CMR (for example, LGE, T1-mapping, and volumetrics) may be considered for prognostication in HFpEF; studies have reported prognostic thresholds (e.g., LV mass >133.24 g, LGE fibrosis >34.86%, native T1 >1056.42 ms) but authors note the need for larger prospective validation before widespread adoption.
Off-label ferumoxytol use considerations
When using ferumoxytol as an MRI contrast agent, providers should document the rationale for off-label use; be aware that reported diagnostic doses vary (e.g., 1–11 mg/kg), immediate adverse event rates are approximately 2% with rare severe reactions and no deaths reported in pooled analyses/registries, and ferumoxytol’s prolonged intravascular persistence may affect subsequent image interpretation.
Policy effective and review dates
Policy effective date and review schedule:
MRI uses pulsed radiofrequency in a high magnetic field to generate high-resolution, multi-planar images and mapping techniques; it provides superior soft-tissue contrast, no ionizing radiation, and can acquire 2D/3D/4D data but requires longer acquisition times and patient cooperation and is contraindicated with many ferromagnetic implants and most pacemakers.
Contrast-enhanced CMR commonly uses gadolinium-based agents (listed examples include Magnevist, ProHance, Omniscan) to shorten relaxation times and enhance T1-weighted images; alternative agents such as ferumoxytol (an ultra-small superparamagnetic iron oxide nanoparticle, FDA-approved as an IV therapeutic) have been used off-label for vascular and pediatric CHD imaging but remain investigational for many cardiac indications.
CMR is complementary to echocardiography, CT and nuclear imaging: echocardiography remains first-line for many cardiac assessments but CMR is valuable when echo is inconclusive or limited (better RV assessment, volumetrics, tissue characterization); coronary CT angiography and CMR both detect anomalous coronaries; MRI avoids ionizing radiation compared with CT and nuclear techniques.
Late gadolinium enhancement CMR (LGE-CMR) identifies myocardial fibrosis/scar and has prognostic value: meta-analyses and cohort studies report associations of LGE with increased cardiac and all-cause mortality and with ventricular arrhythmic events in hypertrophic cardiomyopathy and dilated cardiomyopathy.
Investigational or evolving techniques include blood oxygenation level–dependent (BOLD) cardiac MRI, intravascular MRI for vulnerable plaque detection, whole-heart coronary MRI for noninvasive coronary evaluation, quantitative T1/T2 mapping and novel ferumoxytol-enhanced 4D techniques for pediatric congenital heart disease; these approaches show promise but require further validation.
| Study / Evidence | Key finding |
|---|---|
| Green et al (2012) meta-analysis | LGE-CMR correlated with cardiac death (pooled OR 2.92), heart failure death (OR 5.68), all-cause mortality (OR 4.46); trend toward predicting sudden death. |
| Gulati et al (2013) | Mid-wall fibrosis on LGE associated with increased all-cause mortality (HR 2.96) and arrhythmic events (HR 5.24) in dilated cardiomyopathy. |
| Scott et al (2013) meta-analysis | Extent of LV scar on LGE-CMR strongly associated with ventricular arrhythmias (RR 4.33). |
| Saam et al (2013) meta-analysis on carotid IPH | Presence of carotid intra-plaque hemorrhage predicted cerebrovascular events (HR 5.69); annual event rate 17.71% with IPH vs 2.43% without. |
| Chen et al (2019) meta-analysis on LA/LAA thrombus detection | DE-CMR showed highest diagnostic accuracy: sensitivity 100% and specificity 99% for LA/LAA thrombus among sequences evaluated. |
| Baggen et al (2016) meta-analysis on pulmonary hypertension | RVEF prognostic value: pooled HR 1.23 per 5% decrease (95% CI: 1.07 to 1.41). |
| Myerson et al (2012) AR quantification study | CMR AR quantification predictive of progression to surgery: AUC 0.93; regurgitant fraction >33% associated with progression to surgery. |
| Ribeiro et al (2016) post-TAVR study | Post-TAVR CMRI regurgitant fraction associated with mortality (HR 1.18 per 5% increase); RF ≥30% predicted poorer outcomes. |
| Assadi et al (2021) HFpEF prognostic meta-analysis | Pooled hazard ratio for CMR prognostication in HFpEF: HR 1.52 (95% CI: 1.05 to 1.99). |
| Nguyen et al (2019) ferumoxytol registry | Ferumoxytol adverse reactions: 83/4,240 (1.9%) related/possibly related AEs; no severe/fatal AEs reported. |
| Ahmad et al (2021) ferumoxytol systematic review | Pooled immediate adverse event proportion ~0.02 (2%); 88% mild, 11% moderate, 1% severe; no deaths reported. |
| Garg et al (2021) HFpEF prognostic thresholds | Reported prognostic thresholds: LV mass >133.24 g (HR 1.58); LGE fibrosis >34.86% (HR 1.77); native T1 >1056.42 ms (HR 2.36). |
LGE — Late gadolinium enhancement imaging used to identify myocardial fibrosis/scar.
CMR — Cardiovascular magnetic resonance imaging (cardiac MRI).
ECV — Extracellular volume fraction measured by T1 mapping on CMR, reflecting myocardial interstitial expansion such as amyloid deposition.
RF — Regurgitant fraction — percentage of backward flow relative to forward flow measured by phase-contrast CMR.
DE-CMR — Delayed-enhancement cardiac magnetic resonance imaging, a sequence sensitive to myocardial scar and thrombus.
Ferumoxytol — An ultra-small superparamagnetic iron oxide nanoparticle FDA-approved for IV treatment of iron deficiency (therapeutic) and used off-label as an MRI contrast agent.
LGE — Late gadolinium enhancement, a CMR technique to detect myocardial scar/fibrosis.
HFpEF — Heart failure with preserved ejection fraction.
Policy effective/review dates from document
Policy effective/review dates from document
Policy effective/review dates from document