Aetna Cardiac MRI Coverage Policy Update

Coverage Summary

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.

Policy metadata and thresholds summary

Effective date2001-01-21

Last review2023-08-01

Next review2024-05-23

Coverage stancecovered_with_criteria

Scope summaryDefines 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.

Investigational procedures presentYes — policy lists specific experimental/investigational techniques (e.g., intravascular MRI, BOLD cardiac MRI, ferumoxytol uses, whole-heart coronary MRI).

Thresholds (names only)Myocardial extracellular volume (ECV) cutoff for amyloid; Aortic regurgitant fraction (post-TAVR) threshold associated with poorer outcomes; Regurgitant fraction (general AR) threshold predicting progression to surgery; T2 relaxation time suggestive of transplant rejection (pilot study); LV mass threshold; LGE-fibrosis threshold; Native T1 threshold

Medically Necessary Indications

Experimental and Investigational (Not Medically Necessary)

Coding

Covered CPT codes if selection criteria are metCPTCovered

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.

Other related CPT codes (related to CPB)CPT

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.

Covered HCPCS codes if selection criteria are metHCPCSCovered

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.

HCPCS codes not covered for indications listed in the CPBHCPCSNot Covered

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).

Other HCPCS codes related to the CPBHCPCS

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.

Covered ICD-10 codes if selection criteria are met (selection shown, not all-inclusive)ICD-10Covered

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.

1–10 of 60

1/6

ICD-10 codes not covered for indications listed in the CPBICD-10Not Covered

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.

Provider Actions & Operational Notes

Documentation Required

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.

Prior Authorization

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.

Documentation Required

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.

Background & Evidence

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).

Definitions

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.

Revision History

2001-01-21Effective

Policy effective/review dates from document

2023-08-01Last reviewLatest

Policy effective/review dates from document

2024-05-23Next review

Policy effective/review dates from document

OpenPayer

Magnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI

Coverage Summary

Medically Necessary Indications

Experimental and Investigational (Not Medically Necessary)

Coding

Provider Actions & Operational Notes

Background & Evidence

Definitions

Revision History