Currentblue cross blue shield - kansasPolicy N/A

Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Head, Neck, Abdomen, Pelvis, and Lower Extremities

Medical policy governing clinical indications, documentation, and coding for CTA and MRA of the head, neck, abdomen, pelvis, and lower extremities for Blue Cross and Blue Shield of Kansas members.

Policy Summary

Payerblue cross blue shield - kansas

PolicyComputed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Head, Neck, Abdomen, Pelvis, and Lower Extremities

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 13, 2016

Next Review Date

Key ActionSubmit a predetermination request or contact BCBSKS customer service to verify member benefits or address coverage questions prior to service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5body regions covered

26+coding entries provided

2016effective date

100+diagnoses listed

Coverage Criteria for CTA / MRA

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inv-01: Covered Indications by Region

CTA or MRA may be considered medically necessary when the following indication-specific criteria are met:

Head indications: patients suspected of having steno-occlusive disease of the mid or large size intracranial arteries OR suspected cerebral aneurysm OR suspected intracranial vascular malformation OR suspected cerebral venous sinus compression or thrombosis OR patients with pulsatile tinnitus

from policy head section

inv-24: Head vascular evaluation

Head vascular evaluation: suspected intracranial steno-occlusive disease OR suspected cerebral aneurysm OR suspected intracranial vascular malformation OR suspected cerebral venous sinus compression or thrombosis OR pulsatile tinnitus

from policy 1

inv-25: Neck vascular evaluation

Neck vascular evaluation: suspected carotid stenosis or occlusion OR suspected cervicocranial arterial dissection

from policy 2

inv-26: Abdominal/pelvic vascular evaluation

Abdominal/pelvic vascular evaluation

Renal artery stenosis subcriteria: (1) patients with documented hypertension with any of: abrupt onset; accelerated progression; onset before age 20; refractory to at least 2 conventional medications; (2) renal insufficiency unexplained or induced by angiotensin-converting enzyme inhibitors; (3) unilateral small kidney; (4) renal artery bruits
from policy 3.a

inv-27: Peripheral vascular evaluation

Peripheral vascular evaluation: patients with suspected atherosclerotic disease of the lower extremity in whom angiography would otherwise be indicated and CTA/MRA would obviate the need for angiography OR patients with known atherosclerotic lower extremity disease being evaluated for bypass when angiography fails to identify runoff vessels suitable for bypass

from policy 4 and lower extremity section

inv-02: Pelvis / Lower Extremity

Pelvis/Lower extremities: suspected atherosclerotic disease of the lower extremity where angiography would otherwise be indicated OR known disease being evaluated for bypass when angiography fails to identify runoff vessels suitable for bypass

from policy pelvis/lower extremity section

The list of procedure, diagnosis, and device codes shown in this policy is provided for informational purposes only. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Always refer to the member's contract benefits in effect at the time of service to determine coverage or noncoverage for an individual member.

This policy has undergone multiple revisions during which several previously listed medically necessary indications were removed or refined. Examples of these changes and the dates of revision are documented in the REVISIONS section of the policy.

Within the provided policy excerpts there are no explicit statements categorizing specific CTA/MRA procedures as "not medically necessary." The document does, however, note that coding lists are informational and that coverage determinations depend on the member contract and clinical documentation.

Revision notes indicate that specific prior medically necessary upper extremity CTA/MRA indications were removed. Examples cited in the revisions include preoperative planning uses such as evaluation related to renal tumor resection and surgical planning for kidney donors, and other upper extremity indications were similarly removed or refined in later updates.

inv-28: Historical indications removed/refined

Policy revisions removed or refined some previously listed indications; examples from the revision history include removal of certain preoperative planning items and upper extremity indications.

Historical indications removed or refined: Policy historically included indications such as assessment related to renal tumor resection planning, surgical planning for kidney donor, and various upper extremity indications (e.g., evaluation of a dialysis graft, Raynaud's syndrome, arterial entrapment, suspected aneurysm/AV malformation/fistula/vasculitis or intramural hematoma); these were removed or refined in later revisions (see revision notes).

from policy revisions section

Upper extremity CTA/MRA indications that had been listed in earlier versions of the policy were removed during subsequent revisions. See the REVISIONS section for the dates and details of the changes that resulted in removal of those upper extremity indications.

Coding — CPT/HCPCS and ICD-10

CPT/HCPCSmixed

70496	Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing.
70498	Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing.
70544	Magnetic resonance angiography, head; without contrast material(s).
70545	Magnetic resonance angiography, head; with contrast material(s).
70546	Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences.
70547	Magnetic resonance angiography, neck; without contrast material(s).
70548	Magnetic resonance angiography, neck; with contrast material(s).
70549	Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences.
72191	Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing.
72198	Magnetic resonance angiography, pelvis, with or without contrast material(s).

1–10 of 26

1/3

ICD-10 Diagnoses (partial list)ICD-10

H93.11	Tinnitus, right ear
H93.12	Tinnitus, left ear
H93.13	Tinnitus, bilateral
H93.A1	Pulsatile tinnitus, right ear
H93.A2	Pulsatile tinnitus, left ear
H93.A3	Pulsatile tinnitus, bilateral
I60.01	Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation
I60.02	Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation
I60.11	Nontraumatic subarachnoid hemorrhage from right middle cerebral artery
I60.12	Nontraumatic subarachnoid hemorrhage from left middle cerebral artery

1–10 of 22

1/3

ICD-10 DiagnosesICD-10Covered

I63.033	Cerebral infarction due to thrombosis of bilateral carotid arteries
I63.09	Cerebral infarction due to thrombosis of other precerebral artery
I63.10	Cerebral infarction due to embolism of unspecified precerebral artery
I63.111	Cerebral infarction due to embolism of right vertebral artery
I63.112	Cerebral infarction due to embolism of left vertebral artery
I63.113	Cerebral infarction due to embolism of bilateral vertebral arteries
I63.12	Cerebral infarction due to embolism of basilar artery
I63.131	Cerebral infarction due to embolism of right carotid artery
I63.132	Cerebral infarction due to embolism of left carotid artery
I63.133	Cerebral infarction due to embolism of bilateral carotid arteries

1–10 of 102

1/11

Refractory hypertension trial — requirement

Refractory hypertension requirementPatient blood pressure refractory to at least 2 conventional antihypertensive medications

Context in policyListed as one of the renal artery stenosis subcriteria under abdomen/pelvis indications for CTA/MRA

Documentation implicationClinical record must document refractory hypertension as part of medical necessity justification

Policy revisions count and timeline

Revision history spanMultiple documented revision dates including items from 2007, 2011, 2012, 2014, 2015 and policy effective date Jan 13, 2016

Notable archival actionPolicy published 12-14-2015 and effective 01-13-2016; archival/website notes indicate later archiving

Specific revisions examplesChanges included adding ICD-10 codes (2014), adding CPT 74174 (2012), clarifying renal artery stenosis and aneurysm repair language, and removal of some preoperative indications

Provider Actions and Documentation Requirements

Prior Authorization

Predetermination / Verify Benefits

If there are questions about coverage of this service, contact Blue Cross and Blue Shield of Kansas Customer Service, your professional or institutional relations representative, or submit a predetermination request. Verify member benefits prior to service.

Contact BCBSKS Customer Service for benefit verification
Submit a predetermination request when coverage is uncertain or to confirm benefits prior to service
Professional or institutional relations representative may assist with coverage questions

Documentation Required

Documentation Requirement

Clinical records must document medical necessity. Diagnosis alone is not sufficient; include supporting clinical findings, relevant imaging results, treatment history, and rationale for performing CTA/MRA.

Document clinical indication(s) that meet policy criteria (e.g., suspected steno-occlusive disease, aneurysm, vascular malformation, venous thrombosis, pulsatile tinnitus, carotid stenosis/dissection, renal artery stenosis, chronic mesenteric ischemia, evaluation prior to AAA repair, portal/hepatic venous evaluation)
Include prior noninvasive testing, symptoms onset/progression, and response to prior treatments when applicable
Attach relevant reports/images that support the need for CTA/MRA

Prior Authorization

CTA/MRA Predetermination Recommended

For CTA/MRA of the head, neck, or abdomen/pelvis, predetermination is recommended when coverage is unclear or when verifying member benefits prior to service.

Predetermination recommended for CTA/MRA to confirm medical necessity and coverage
Use predetermination to avoid unexpected denials or member liability

Note

Provider Action — Plan/Contract Precedence

State and federal mandates and member contract language take precedence over this policy. If the member is covered under a different Blue Cross and Blue Shield plan, refer to that plan's medical policies.

Verify plan-specific exclusions or provisions before authorization
If patient covered by another BCBS plan, consult that plan's policies

Contrast and Radiation Considerations

Billing Rule

MRA contrast use and relative risk

MRA may be performed with or without intravenous contrast depending on the clinical application; contrast agents used for MRA are associated with less risk of allergic reaction or nephrotoxicity than those used for conventional angiography.

Select contrast use based on clinical application and renal function.

Billing Rule

CTA involves iodinated contrast and ionizing radiation

CTA uses iodinated contrast material and involves ionizing radiation; consider radiation exposure and the risk of iodinated contrast reactions or nephrotoxicity when ordering CTA.

Weigh benefits of CTA against radiation exposure and iodinated contrast risks.

Note

References on contrast-enhanced MRA; no extra in-policy rules provided

Although references discuss contrast-enhanced MRA for preoperative evaluations (for example, living renal donors), the provided document fragments do not state additional in-policy contrast rules beyond selection based on application.

Definitions and Policy Guidelines

MRV definition

DefinitionMagnetic resonance venography (MRV) is the term used when MR is used to image a vein instead of an artery

Modality relationshipMRV is a subset/usage of MRA terminology when venous structures are the target

Clinical noteMRV is referenced in context of MRA description; use appropriate MR venous techniques based on clinical question

MRA suitability for vessel size and examples

Appropriate vessel sizeMRA technical capabilities make it most suitable for evaluation of medium-to-large size vessels (e.g., Circle of Willis, aorta and major branches)

Head examplesIn the head, includes the Circle of Willis and major posterior circulation vessels

Body examplesIn the body, includes the aorta and major arterial branches such as carotid, renal, hepatic and mesenteric arteries

Policy guidelines and historical indication changes

Clarified indicationsRevisions clarified assessment related to renal artery stenosis including specified subcriteria (e.g., refractory hypertension) and modified wording for elective abdominal aortic aneurysm repair

Removed/refined indicationsSome previously listed indications were removed (examples: planning for renal tumor resection, surgical planning for kidney donor, and certain preoperative items)

Policy guideline additionsA Policy Guidelines section was added in revisions to clarify use and selection criteria

Computed tomographic angiography (CTA) uses iodinated contrast material and ionizing radiation to produce cross-sectional vascular images. When ordering CTA, consider the radiation exposure and the risk of iodinated contrast reactions or nephrotoxicity. Magnetic resonance angiography (MRA) uses MR technology and may be performed with or without intravenous contrast depending on the clinical application; contrast agents used with MRA generally carry lower allergic and nephrotoxicity risks than iodinated contrast.

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