CAM 60116

Magnetic Resonance Angiography of Vessels of the Head, Neck, Abdomen, Pelvis and Lower Extremity

Category:Radiology   Last Reviewed:November 2019
Department(s):Medical Affairs   Next Review:November 2020
Original Date:July 1997    

Description:
Magnetic resonance angiography (MRA) is a technique for imaging vascular anatomy and pathology that does not use ionizing radiation. MRA is performed using magnetic resonance imaging (MRI) machines, and vascular images may be generated either with or without intravenous contrast agents, depending on the clinical application. However, the contrast agents used for MRA are associated with less risk of allergic reaction or nephrotoxicity than those used for conventional angiography. MRA is the general term used to describe MR imaging of vascular structures, but when MR is used to image a vein instead of an artery, the term "magnetic resonance venography" (MRV) may be used. The technical capabilities of current MRA make it most suitable for evaluation of medium-to-large size vessels. In the head, this includes the Circle of Willis and major posterior circulation vessels, while in the body this includes the aorta and its major arterial branches such as carotid, renal, hepatic and mesenteric arteries. MRA is less suitable for providing detailed information about the small, peripheral vasculature.

Policy:
MRA/MRV of the brain (head) is considered MEDICALLY NECESSARY for the following: 

INDICATIONS FOR BRAIN (HEAD) MRA/MRV: 

For evaluation of known intracranial vascular disease: 

  • Known intracranial aneurysm or arteriovenous malformation (AVM).
  • Known vertebrobasilar insufficiency (VBI).
  • Vascular abnormality visualized on previous brain imaging.
  • Known vasculitis, reversible cerebral vasoconstriction syndrome or Moyomoya disease 

For evaluation of suspected intracranial vascular disease: 

  • Screening for suspected intracranial aneurysm in patient with a first-degree familial history (parent brother, sister, or child) of intracranial aneurysm. Note: Repeat study is recommended every 5 years.
  • Screening for aneurysm in polycystic kidney disease, Ehlers-Danlos syndrome, fibromuscular dysplasia, neurofibromatosis, or known aortic coarctation.
  • Clinical suspicion of subarachnoid hemorrhage (SAH) (i.e., thunderclap headache)
  • Known subarachnoid hemorrhage (SAH)
  • Spontaneous intracerebral hemorrhage with concern for underlying vascular abnormality
  • Known or suspected vertebrobasilar insufficiency (VBI) in patients with symptoms such as dizziness, vertigo, headaches, diplopia, blindness, vomiting, ataxia and weakness in both sides of the body, or abnormal speech
  • Suspected arteriovenous malformation (AVM) in patient with previous or indeterminate imaging study.
  • Suspected central venous thrombosis (dural sinus thrombosis) - ordered as MRV see background
  • Distinguishing benign intracranial hypertension (pseudotumor cerebri) from dural sinus thrombosis
  • Pulsatile tinnitus to identify a vascular etiology.
  • Suspected vasculitis with abnormal lab results suggesting acute inflammation or autoimmune antibodies.
  • Suspected primary CNS vasculitis with infectious/inflammatory lab work-up, reversible cerebral vasoconstriction syndrome or Moyomoya disease
  • Stroke risk in sickle cell patients (2 - 16 years of age) with a transcranial doppler velocity > 200.
  • Neurological signs or symptoms in sickle cell disease
  • Refractory trigeminal neuralgia when done for surgical plann 

Pre-operative/procedural evaluation for treatment, procedure, intervention, or brain/skull surgery.

Post-operative/procedural evaluation:

  • A follow-up study may be needed to help evaluate a patient’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. 

Indications for Brain MRA/Neck MRA combination studies:    

  • Recent stroke or transient ischemic attack (TIA)
  • Known or suspected carotid or cerebral artery occlusion in patients with a sudden onset of one-sided weakness or numbness, abnormal speech, vision defects, incoordination or severe dizziness.
  • Known or suspected vertebrobasilar insufficiency (VBI) in patients with symptoms such as dizziness, vertigo, headaches, diplopia, blindness, vomiting, ataxia and weakness in both sides of the body, or abnormal speech
  • Head trauma in a patient with closed head injury with suspected carotid or vertebral artery dissection; or spontaneous injuries due to weakness of vessel wall leading to dissection.
  • Pulsatile tinnitus to identify vascular etiology.
  • Asymptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g. carotid stenosis ≥ 70%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) and patient is surgery or angioplasty candidate 
  • Symptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g. carotid stenosis ≥ 50%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) and patient is surgery or angioplasty candidate   

Indications for Brain MRI/Brain MRA combination studies: 

  • Recent stroke or transient ischemic attack
  • Clinical suspicion of subarachnoid hemorrhage (SAH) ie thunderclap headache
  •  Suspected venous thrombosis (dural sinus thrombosis) MRV*  

Indications for Brain MRI/Brain MRA/Neck MRA combination studies:   

  • Recent stroke or transient ischemic attack (TIA)
  • Approved indications as noted above and being performed in a child under 8 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial pathology

NECK MRA is considered MEDICALLY NECESSARY for the following indications: 

For evaluation of vascular disease:

  • Asymptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g. carotid stenosis ≥ 70%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries).
  • For evaluation of symptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g. carotid stenosis ≥ 50%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries).
  • For evaluation of head or neck blunt injury for suspected carotid or vertebral artery dissection.
    • Focal or lateralizing neurological deficits
    • Face or cervical fractures
    • Cervical hematomas
    • Injury by severe cervical hyperextension/rotation or hyperflexion, or “clothesline”
    • Thoracic injury

Findings of Takayasu arteritis in other blood vessels
May be useful in defining giant cell arteritis
Subclavian steal syndrome when ultrasound is positive or indeterminant or for planning interventions

For evaluation of known or suspected tumor/pulsatile mass:

  • For evaluation of carotid body tumors, or other masses such as a paraganglioma, arteriovenous fistula pseudoaneurysm, atyptical lymphovascular malformation (Nguyen, 2011)

Note: US may be used to identify a mass overlying or next to an artery in initial work up of a pulsatile mass.  

Pre-operative evaluation.

Post-operative/procedural evaluation (e.g. carotid endarterectomy):

  • A follow-up study may be needed to help evaluate a patient’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.

Neck MRA/Brain MRA: 

  • Evaluation of new onset stroke or transient ischemic attack (TIA)
  • For evaluation of known or suspected vertebrobasilar insufficiency (VBI) in patients with symptoms such as dizziness, vertigo, headaches, diplopia, blindness, vomiting, ataxia and weakness in both sides of the body, or abnormal speech
  • Head or neck blunt injury for suspected carotid or vertebral artery dissection (Franz, 2012; Mundinger, 2013); or spontaneous injuries due to weakness of vessel wall leading to dissection. Patients with blunt cervical trauma who meet Denver Screening criteria should be assessed for cerebrovascular injury (although about 20% will not meet criteria). The criteria include:
    • Focal or lateralizing neurological deficits (not explained by head CT)
    • Infarct on head CT
    • Face, basilar skull or cervical spine fractures
    • Cervical hematomas that are not expanding
    • Glasgow coma score less than 8 without CT finding
    • Massive epistaxis
    • Cervical bruit or thrill
  • For evaluation of pulsatile tinnitus (subjective or objective) for vascular etiology.
  • Asymptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g. internal carotid stenosis > 70%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) and patient is surgery or angioplasty candidate.
  • For evaluation of symptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g. carotid stenosis ≥ 50%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) and patient is surgery or angioplasty candidate. 

PELVIS MRA:

PELVIS MRA: Abdominal MRA can be added when indicated*:

For evaluation of known or suspected pelvic vascular disease: 

  • For pelvic extent of known large vessel diseases (abdominal aorta, inferior vena cava, superior/inferior mesenteric, celiac, splenic, renal or iliac arteries/veins), e.g., aneurysm, dissection, arteriovenous malformations (AVMs), and fistulas, intramural hematoma, and vasculitis.
  • Evidence of vascular abnormality seen on prior imaging studies.
  • For suspected pelvic extent of aortic dissection.
  • Evaluation of known or suspected aneurysms limited to the pelvis or in evaluating pelvic extent of aortic aneurysm **
    • Known or suspected iliac artery aneurysm >2.5 cm AND equivocal or indeterminate ultrasound results

OR

    • Prior imaging (e.g. ultrasound) demonstrating iliac artery aneurysm >2.5 cm in diameter

OR

    • Suspected complications of known aneurysm as evidenced by clinical findings such as new onset of pelvic pain.
  • Follow up of iliac artery aneurysm: Six month if between 3.0 - 3.5 cm and if stable follow yearly. If >3.5 cm, <six month follow up (and consider intervention).
  • Retroperitoneal hematoma or hemorrhage when an underlying neoplasm is suspected and prior imaging is inconclusive.*
  • For evaluation of suspected pelvic vascular disease when findings on ultrasound are indeterminate (MR or CT venography may be used as the initial study for evaluating pelvic thrombosis or thrombophlebitis).
  • Venous thrombosis if previous studies have not resulted in a clear diagnosis.
  • Vascular invasion or displacement by tumor (Conventional CT or MRI also appropriate).
  • Pelvic vein thrombosis or thrombophlebitis.
  • For suspected May-Thurner Syndrome (iliac vein compression syndrome)
  • For chronic mesenteric ischemia
  • Acute mesenteric ischemia assess with CTA unless contraindicated.

Pre-operative evaluation:

  • Evaluation of interventional vascular procedures prior to endovascular aneurysm repair (EVAR), or for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia.

Post- operative or post-procedural evaluation:

  • Evaluation for post-operative complications of renal transplant allograft
  • Evaluation of endovascular/ interventional vascular procedures for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia.
  • Evaluation of post-operative complications, e.g. pseudoaneurysms, related to surgical bypass grafts, vascular stents and stent-grafts in the peritoneal cavity.
  • Follow-up for post-endovascular repair (EVAR) or open repair of abdominal aortic aneurysm (AAA) and iliac artery aneurysms. Routine, baseline study (post-op/intervention) is warranted within 1-3 months.
    • Asymptomatic at six (6) month intervals, for one (1) year, then annually.
    • Symptomatic/complications related to stent graft – more frequent imaging may be needed.
  • Follow-up study may be needed to help evaluate a patient’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.

ABDOMEN MRA is considered MEDICALLY NECESSARY for the following:

For evaluation of known or suspected abdominal vascular disease:

  • For known large vessel diseases (abdominal aorta, inferior vena cava, superior/inferior mesenteric, celiac, splenic, renal or iliac arteries/veins), e.g., aneurysm, dissection, arteriovenous malformations (AVMs), and fistulas, intramural hematoma, and vasculitis.
  • For diagnosis or follow up of visceral artery aneurysm
  • Evidence of vascular abnormality seen on prior imaging studies and limited to the abdomen..
  • Evaluation of known or suspected aortic aneurysm**:
    • Known or suspected aneurysm > 2.5 cm AND equivocal or indeterminate ultrasound results OR
    • Prior imaging (e.g. ultrasound) demonstrating aneurysm >2.5 cm in diameter OR
    • Suspected complications of known aneurysm as evidenced by signs/symptoms such as new onset of abdominal or pelvic pain.
  • To determine the vascular source of retroperitoneal hematoma or hemorrhage when CTA is contraindicated**
  • Suspected renal vein thrombosis in patient with known renal mass or from other causes.
  • For evaluation of suspected acute mesenteric ischemia/ischemic colitis when CTA is contraindicated**
  • For suspected chronic mesenteric ischemia***
  • Venous thrombosis if previous studies have not resulted in a clear diagnosis.
  • Vascular invasion or displacement by tumor.
  • For evaluation of hepatic blood vessel abnormalities (aneurysm, hepatic vein thrombosis, stenosis post transplant) after doppler ultrasound has been performed; to clarify or further evaluate ultrasound findings.
  • For evaluation of transjugular intrahepatic portosystemic shunt (TIPS) when Doppler ultrasound indicates suspected complications.
  • Kidney failure or renal insufficiency if initial evaluation performed with Ultrasound is inconclusive.
  • For evaluation of known or suspected renal artery stenosis or resistant hypertension in the setting of normal renal function or impaired renal function unrelated to recent medication demonstrated by any of the following:
    • Unsuccessful control after treatment with 3 or more (>2) anti-hypertensive medication at optimal dosing.
    • Acute elevation of creatinine after initiation of an angiotension converting enzyme inhibitor (ACE inhibitor) or angiotension receptor blocker (ARB).
    • Asymmetric kidney size noted on ultrasound.
    • Onset of hypertension in a person younger than age 30 without any other risk factors or family history of hypertension.
    • Significant hypertension (diastolic blood pressure > 110 mm Hg) in a young adult (i.e., younger than 35 years) suggestive of fibromuscular dysplasia
    • Diagnosis of a syndrome with a higher risk of vascular disease, such as neurofibromatosis, tuberous sclerosis and Williams’ syndrome
    • New onset of hypertension after age 50.
    • Acute rise in blood pressure in a person with previously stable blood pressures.
    • Flash pulmonary edema without identifiable causes.
    • Malignant hypertension.
    • Bruit heard over renal artery and hypertension.

Pre-operative evaluation:

  • Evaluation prior to interventional vascular procedures for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia.
  • For pre transplant evaluation of either liver or kidney.
  • Imaging of the deep inferior epigastric arteries for surgical planning (breast reconstruction surgery), include pelvic MRA

Post-operative or post-procedural evaluation:

  • Evaluation of endovascular/interventional abdominal vascular procedures for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia.
  • Evaluation of post-operative complications, e.g. pseudoaneurysms, related to surgical bypass grafts, vascular stents, and stent-grafts in the peritoneal cavity.
  • Follow-up for post-endovascular repair (EVAR) or open repair of abdominal aortic aneurysm (AAA) or abdominal extent of iliac artery aneurysms. Routine, baseline study (post-op/intervention) is warranted within 1-3 months . 
    • Asymptomatic at six (6) month intervals for one (1) year, then annually.  
  • Symptomatic/complications related to stent graft – more frequent imaging may be needed. 
  • Follow-up study may be needed to help evaluate a patient’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.

INDICATIONS FOR UPPER EXTREMITY MRA/MRV:

For assessment/evaluation of known or suspected vascular disease/condition:

  • For evaluation of suspected vascular disease: aneurysm, arteriovenous malformation, fistula, vasculitis, or intramural hematoma.
  • For evaluation of Raynaud's syndrome.
  • For evaluation of vascular invasion or displacement by tumor.
  • For evaluation of suspected upper extremity embolism or thrombosis.
  • For evaluation of traumatic injuries to the upper extremity with clinical findings suggestive of arterial injury.
  • Suspected fibromuscular dysplasia of the brachial artery.

Pre-operative/procedural evaluation:

  • Pre-operative evaluation for a planned surgery or procedure.

Post-operative/procedural evaluations:

  • Post-operative or interventional vascular procedure for luminal patency versus re-stenosis (due to atherosclerosis, thromboembolism, intimal hyperplasia and other causes), as well as complications such as pseudoaneurysms related to surgical bypass grafts and vascular stents and stent-grafts.
  • A follow-up study may be needed to help evaluate a patient’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.  

INDICATIONS FOR LOWER EXTREMITY MRA/MRV:

  • Critical Limb ischemia AND any of the below with clinical signs of peripheral artery disease. Ultrasound imaging is not needed. If done and negative, it should still be approved due to high false negative rate 
    • Ischemic rest pain
    • Tissue loss
    • Gangrene
  • Claudication with abnormal (ankle/brachial index, pulse volume recording or arterial Doppler
  • Clinical concern for vascular cause of ulcers with abnormal or indeterminate ultrasound (ankle/brachial index, arterial Doppler) 
  • After stenting or surgery with signs of recurrent symptoms OR abnormal ankle/brachial index ; abnormal or indeterminate arterial Doppler, OR pulse volume recording)  

Popliteal Artery Entrapment Syndrome with abnormal arterial ultrasound 

Deep Venous Thrombosis with clinical suspicion of lower extremity DVT after abnormal or non-diagnostic ultrasound where a positive study would change management.

Clinical suspicion of vascular disease with abnormal or indeterminate ultrasound or other imaging  

  • Peripheral vascular malformations (PVM)
  • Tumor invasion
  • Trauma
  • Vasculitis
  • Aneurysm 
  • Steno-occlusions

For assessment/evaluation of suspected or known vascular disease/condition

Pre-operative/procedural evaluation:

  • Pre-operative evaluation for a planned surgery or procedure.

Post-operative/procedural evaluation:

  • A follow-up study may be needed to help evaluate a patient’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.  

All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.

Policy Guidelines:
Invasive cerebral angiography has been traditionally considered the reference standard to which the performance of noninvasive diagnostic tests is compared. Both magnetic resonance angiography (MRA) and transcranial Doppler ultrasonography (TCD) have been shown to be effective noninvasive diagnostic tests for evaluating patients suspected of having intracranial arterial steno-occlusive disease and may be used by some physicians as a replacement for invasive cerebral angiography.In some circumstances, either MRA or TCD alone may provide adequate information to guide appropriate management; however, there are other circumstances whereby it may be necessary to obtain both noninvasive tests before management decisions can be made. For example, the initial noninvasive study may be technically limited by patient motion (particularly a problem for MRA) or by the patient having an inadequate acoustic window (a problem unique to TCD). When this is the case, diagnostic information may be sought using the alternative noninvasive imaging tool. Furthermore, the results of the initial noninvasive evaluation may be borderline or equivocal. Since CDUS and MRA use different physical and technical principles for evaluating the cerebral vasculature, the information obtained from each test can be complementary rather than duplicative in some circumstances. 

Neck
Invasive angiography of the cervical carotid arteries has been used traditionally as the definitive preoperative diagnostic evaluation in patients with carotid artery bifurcation stenosis who are being considered for carotid endarterectomy (CEA). However, as recent improvements have been made in noninvasive diagnostic tests to evaluate the carotid bifurcation region, some physicians have favored a preoperative diagnostic approach using noninvasive imaging tests such as carotid duplex ultrasonography (CDUS) and/or MRA to guide management decisions.

CDUS is most commonly used as the initial noninvasive evaluation of the carotid bifurcation as it is less expensive than MRA and generally more readily available than MRA. When the clinical suspicion for steno-occlusive disease is considered along with the results of the initial test (usually CDUS), the physician can decide whether there is sufficient information to determine subsequent management for the patient or whether additional imaging is necessary. One imaging strategy that has emerged and that is supported in the available evidence, uses both CDUS and MRA to evaluate patients prior to CEA. When both noninvasive tests agree as to the necessity of CEA, the surgical management decision is made based on noninvasive imaging alone. However, if there is discordance in the results of MRA and CDUS (e.g., 1 test suggests a severe carotid stenosis but the other test suggests only a mild-to-moderate degree of stenosis), then invasive angiography is performed to determine the management decision. Using this combination strategy, the utilization of invasive angiography for preoperative evaluation for CEA has been reported to decrease substantially.

Abdomen
A variety of abdominal vascular conditions have been proposed for evaluation with contrast-enhanced MRA. Patients who are suspected of having renal artery stenosis may benefit when MRA is used to rule out significant stenosis, thus sparing the patient from invasive angiography. Patients with positive results on MRA may require confirmatory angiography before receiving surgical or intravascular stent treatment for renal artery stenosis. However, confirmation may often be performed during the catheterization for the therapeutic procedure. Similarly, patients with suspected chronic mesenteric ischemia or suspected hepatic arterial disease may benefit from the use of MRA. Potential living renal donors may benefit by using contrast-enhanced MRA for preoperative evaluation of renal anatomy as an alternative to invasive digital subtraction angiography and or computed tomographic angiography (CTA), both of which require ionizing radiation and potentially nephrotoxic iodinated intravenous contrast agents. 

Patients who are to undergo elective repair of an abdominal aortic aneurysm undergo preoperative angiographic evaluation to delineate the size and location of the aneurysm as well as its relationship with renal and other branch arteries. MRA has been proposed as a replacement for invasive angiography in this situation. Similarly, patients who are to undergo abdominal organ transplantation may require presurgical angiography and may benefit from the use of MRA. CTA is also proposed as a noninvasive alternative, though CT uses iodinated contrast agents that pose a higher risk for allergic and nephrotoxic reactions. Patients with suspected abdominal or pelvic venous thrombo-occlusive disease may benefit by using MRA to obviate the need for invasive venography.

Pelvis
Pelvic arteriography or venography may be useful in several situations to avoid the need for invasive angiography. Patients with suspected aorto-iliac atherosclerotic disease may benefit by the use of MRA to avoid the need for invasive angiography, and this evaluation often includes arterial evaluation of the lower extremities as well in patients with suspected peripheral vascular disease (e.g., claudication). Other uses of pelvic MRA would include evaluation of renal arteries with ectopic pelvic location of the kidney and evaluation of pelvic veins for thrombo-occlusive disease. 

Lower Extremity
MRA may be useful for evaluating the arterial and venous structures of the lower extremity. In patients with suspected peripheral vascular disease, MRA may be able to evaluate the extent of disease and guide therapeutic decision making without the need for invasive angiography. Furthermore, MRA may be more sensitive than conventional angiography in identifying distal runoff vessels in potential candidates for peripheral bypass surgery.

Rationale
MRA of the pelvis and lower extremities has emerged as an important tool for surgical planning, particularly to identify patent distal run-off vessels when surgical revascularization is considered. (4–7) In addition, MRA has been widely used to evaluate the recurrent symptoms in patients who have undergone either angioplasty or surgical revascularization. A meta-analysis of 34 studies conducted by Koelemay et al. (8) found that MRA was accurate for identifying stenosis (>50%) or occlusions in the aorto-iliac, femoropopliteal, and infrapopliteal regions. Baum et al. (9) found that MRA is more sensitive for identifying runoff vessels compared with conventional angiography. Use of vessels visible only on MRA for bypass surgery provides an opportunity for limb salvage and when compared with bypass to angiographically visible vessels, graft-patency and limb-salvage outcomes are similar. (10) These roles of MRA are recognized by the American College of Radiology Appropriateness Criteria. (11)

Diagnostic performance of MRA of the abdomen for evaluation of renal anatomy in potential living renal donors has improved with the evolution of contrast-enhanced MRA techniques. Recent studies have shown contrast-enhanced MRA to have good sensitivity and specificity for detection of renal arterial and venous anomalies. Three studies reported sensitivity and specificity of 90% or higher for renal arterial anatomy. (12–14) One study examined the ability of contrast-enhanced MRA to detect arterial, venous, ureteral, or parenchymal anomalies during the presurgical evaluation process for laparoscopic nephrectomy. (15) This study found that preoperative MRA agreed completely with surgical findings in 21 of 28 cases (75%). In this study, the laparoscopic surgical procedure was successful in 27 of 28 cases (96%) and only 1 case required conversion to open nephrectomy, suggesting that some oversights on MRA may not be clinically significant. Furthermore, studies comparing contrast-enhanced MRA to alternatives such as computed tomographic angiography (CTA) and digital subtraction angiography have reported comparable results. (14, 16–18) However, concerns have been raised regarding the ability of MRA or CTA to detect mild or distal-moderate fibromuscular dysplasia (FMD) that can be seen on conventional renal angiography. (19) The prevalence of FMD is about 2% to 6.6% in angiographic case series, and it is unclear what effect donor nephrectomy may have on the subsequent development of hypertension in asymptomatic potential renal donors who have silent FMD. (19)

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  37. Bernhardt, S. (2006). Sonography of the carotid body tumor: A literature review. Journal of Diagnostic Medical Sonography, (JDMS), 22(2), 85-89. doi: 10.1177/8756479306286496
  38. DeMarco, J.K., Willinek, W.A., Finn, J.P., & Huston. J. (2012). Current state-of-the-art 1.5 T and 3 T extracranial carotid contrast-enhanced magnetic resonance angiography. Neuroimaging Clin N Am.22(2), 235-57. doi: 10.1016/j.nic.2012.02.007.
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  41. Kohler, R., Vargas, M.I., Masterson, K., Lovblad, K.O., Pereira, V.M., & Becker, M. (2011). CT and MR angiography features of traumatic vascular injuries of the neck. AJR Am J Roentgenol. 196(6), W800-9. doi: 10.2214/AJR.10.5735.
  42. Vertinsky, A.T., Schwartz, N.E., Fischbein, N.J., Rosenberg, J., Albers, G.W., Zaharchuk, G. (2008) Comparison of multidetector CT angiography and MR imaging of cervical artery dissection. AJNR Am J Neuroradiol. 29:1753–60. http://www.ajnr.org/content/29/9/1753 
  43. American College of Radiology. (2014). ACR Appropriateness Criteria® Retrieved from https://acsearch.acr.org/list.
  44. Cohen, E.I., Weinreb, D.B., Siegelbaum, R.H., Honig, S., Marin, M., Weintraub, J.L., & Lookstein, R.A. (2008). Time-resolved MR angiography for the classification of endoleaks after endovascular aneurysm repair. Journal of Magnetic Resonance Imaging, 27(3), 500-503. doi: 10.1002/jmri.21257
  45. Jain, R., & Sawhney, S. (2005). Contrast-enhanced MR angiography (CE-MRA) in the evaluation of vascular complications of renal transplantation. Clinical Radiology, 60(11), 1171-1181. http://dx.doi.org/10.1016/j.crad.2005.05.004,
  46. Jesinger, R.A., Thoreson, A.A., & Lamba, R. (2013). Abdominal and pelvic aneurysms and pseudoaneurysms: Imaging review with clinical, radiologic, and treatment correlation. Radiographics. 33(3), E71-96. doi: 10.1148/rg.333115036.
  47. Khosa F, Krinsky G, Macari M et-al. Managing incidental findings on abdominal and pelvic CT and MRI, Part 2: white paper of the ACR Incidental Findings Committee II on vascular findings. J Am Coll Radiol. 2013;10 (10): 789-94. doi:10.1016/j.jacr.2013.05.021
  48. Maki, J.H., Wilson, G.J., Eubank, W.B., Glickerman, D.J., Millan, J.A., & Hoogeveen, R.M. (2007). Navigator-gated MR angiography of the renal arteries: A potential screening tool for renal artery stenosis. American Journal of Roentgenology, 188(6), W540-546. Retrieved from http://www.ajronline.org/content/188/6/W540.long
  49. Michaely, H.J., Attenberger, U.I., Kramer, H., Nael, K., Reiser, M.F., & Schoenberg, S.O. (2007). Abdominal and pelvic MR angiography. Magn Reson Imaging Clin N Am. 15(3), 301-14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17893051
  50. Patel, S.T., Mills, J.L. Sr, Tynan-Cuisinier, G., Goshima, K.R., Westerband, A., & Hughes, J.D. (2005). The limitations of magnetic resonance angiography in the diagnosis of renal artery stenosis: Comparative analysis with conventional arteriography. Journal of Vascular Surgery: Official Publication, The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter, 41(3), 462-468. Retrieved from http://www.researchgate.net/publication/223844650_The_limitations_of_magnetic_resonance_angiography_in_the_diagnosis_of_renal_artery_stenosis_Comparative_analysis_with_conventional_arteriography
  51. Shih, M.C., & Hagspiel, K.D. (2007). CTA and MRA in mesenteric ischemia: Part 1, role in diagnosis and differential diagnosis. American Journal of Roentgenology, 188, 452-461. Retrieved from http://www.ajronline.org/content/188/2/452.full.pdf+html
  52. Shih, M.P., Angle, J.F., Leung, D.A., Cherry, K.J., Harthun, N.L., Matsumoto, A.H., & Hagspiel, K.D. (2007). CTA and MRA in mesenteric ischemia: Part 2, normal findings and complications after surgical and endovascular treatment. American Journal of Roentgenology, 188, 462-471. Retrieved from http://www.ajronline.org/content/188/2/462.full.pdf+html
  53. Soulez, G., Pasowicz, M., Benea, G., Grazioli, L., Niedmann, J.P., Konopka, M., . . . Kirchin, M.A. (2008). Renal artery stenosis evaluation: diagnostic performance of gadobenate dimeglumine-enhanced MR angiography--comparison with DSA. Radiology, 247(1), 273-285. Retrieved from http://radiology.rsna.org/content/247/1/273.full.pdf+html
  54. Textor, S.C., & Lerman, L. (2010). Renovascular hypertension and ischemic nephropathy. Am J Hypertens. 23(11), 1159-69. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3078640/
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  56. American College of Radiology. (2014). ACR Appropriateness Criteria® Retrieved from https://acsearch.acr.org/list.
  57. Jesinger, R.A., Thoreson, A.A., & Lamba, R. (2013). Abdominal and pelvic aneurysms and pseudoaneurysms: Imaging review with clinical, radiologic, and treatment correlation. Radiographics. 33(3), E71-96. doi: 10.1148/rg.333115036.
  58. Khosa F, Krinsky G, Macari M et-al. Managing incidental findings on abdominal and pelvic CT and MRI, Part 2: white paper of the ACR Incidental Findings Committee II on vascular findings. J Am Coll Radiol. 2013;10 (10): 789-94. doi:10.1016/j.jacr.2013.05.021
  59. Maki, J.H., Wilson, G.J., Eubank, W.B., Glickerman, D.J., Millan, J.A., & Hoogeveen, R.M. (2007). Navigator-gated MR angiography of the renal arteries: A potential screening tool for renal artery stenosis. American Journal of Roentgenology, 188(6), W540-546. Retrieved from http://www.ajronline.org/content/188/6/W540.long
  60. Michaely, H.J., Attenberger, U.I., Kramer, H., Nael, K., Reiser, M.F., & Schoenberg, S.O. (2007). Abdominal and pelvic MR angiography. Magn Reson Imaging Clin N Am. 15(3), 301-14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17893051
  61. Mohler, E.R., & Townsend, R.R. (2006). Advanced therapy in hypertension and vascular. Retrieved from: http://books.google.com/books?hl=en&lr=&id=sCgURxhCJ-8C&oi=fnd&pg=PA224&dq=abdominal+cta+and+hypertension&ots=cJxa6qcpRr&sig=ahv53M5fWFAtEmeLeNyfEFFErPo#PPA227,M1.
  62. Nael, K., Saleh, R., Lee, M., Godinez, S.R., Laub, G., Finn, J.P. & Ruehm, S.G. (2006). High-spatial-resolution contrast-enhanced MR angiography of abdominal arteries with parallel acquisition at 3.0 T: initial experience in 32 patients. American Journal of Roentgenology, 187, W77-85. Retrieved from http://www.ajronline.org/content/187/1/W77.full.pdf+html
  63. Schwope, R.B., Alper, H.J., Talenfeld, A.D., Cohen, E.I., & Lookstein, R.A. (2007). MR angiography for patient surveillance after endovascular repair of abdominal aortic aneurysms. American Journal of Roentgenology, 188, W334-W340. Retrieved from http://www.ajronline.org/content/188/4/W334.full.pdf+html
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  65. Shih, M.C., & Hagspiel, K.D. (2007). CTA and MRA in mesenteric ischemia: Part 1, role in diagnosis and differential diagnosis. American Journal of Roentgenology, 188, 452-461. Retrieved from http://www.ajronline.org/content/188/2/452.full.pdf+html
  66. Shih, M.P., Angle, J.F., Leung, D.A., Cherry, K.J., Harthun, N.L., Matsumoto, A.H., & Hagspiel, K.D. (2007). CTA and MRA in mesenteric ischemia: Part 2, normal findings and complications after surgical and endovascular treatment. American Journal of Roentgenology, 188, 462-471. Retrieved from http://www.ajronline.org/content/188/2/462.full.pdf+html
  67. Soulez, G., Pasowicz, M., Benea, G., Grazioli, L., Niedmann, J.P., Konopka, M., . . . Kirchin, M.A. (2008). Renal artery stenosis evaluation: diagnostic performance of gadobenate dimeglumine-enhanced MR angiography--comparison with DSA. Radiology, 247(1), 273-285. Retrieved from http://radiology.rsna.org/content/247/1/273.full.pdf+html.
  68. Textor, S.C., & Lerman, L. (2010). Renovascular hypertension and ischemic nephropathy. Am J Hypertens. 23(11), 1159-69. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3078640/ 

Coding Section

Codes Number Description
CPT 70544-70546 Magnetic resonance angiography, head, code range
  70547-70549 Magnetic resonance angiography, neck, code range
  73725 Magnetic resonance angiography, lower extremity, with or without contrast material
  74185 Magnetic resonance angiography, abdomen, with or without contrast material
ICD-9 Procedure 88.41 Arteriography of cerebral arteries (includes MRA of head, neck, and spine)
  88.47

Arteriography of intra-abdominal arteries (includes MRA of abdomen)

ICD-9 Diagnosis 388.30-388.32 Tinnitus, code range
  430 Subarachnoid hemorrhage (includes ruptured cerebral aneurysm)
  433.0-433.9 Occlusion and stenosis of precerebral arteries, code range
  434.00-434.91 Occlusion of cerebral arteries, code range (includes thrombosis) code range
  437.0 Cerebral atherosclerosis
  437.3 Cerebral aneurysm
  440.1

Atherosclerosis of renal artery

  441.3-441.9 Abdominal aneurysm
  452 Portal vein thrombosis
  453.0

Budd-Chiari syndrome (hepatic vein thrombosis)

  459.2 Compression of vein
  557.9 Vascular insufficiency of intestine
  571.0-571.9 Chronic liver disease and cirrhosis code range
  747.81 Anomalies of the cerebrovascular system
  747.89 Other specified anomalies of circulatory system (includes congenital aneurysm of specified site not elsewhere classified)
HCPCS A9583 Injection, gadofosveset trisodium, 1 ml. (code for Vasovist/Ablavar – new code 01/01/10)
  C8900-C8902 MRA of the abdomen, code range
  C8912-C8914 MRA of the lower extremity, code range
  C8918-C8920 MRA of the pelvis, code range
ICD-10-CM (effective 10/01/15) H93.11-H93.19 Tinnitus code range
  I60.00 Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon bifurcation
  I66.01-I66.9 Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction code range
  I67.1 Cerebral aneurysm, nonruptured
  I67.2 Cerebral atherosclerosis
  I70.1 Atherosclerosis of renal artery
  I71.3-I71.4 Abdominal aortic aneurysm code range
  I81

Portal vein thrombosis

  I82.0

Budd-Chiari syndrome

  I87.4

Compression of vein

  K55.9

Vascular insufficiency of the intestine

  K74.0-K76.9

Cirrhosis and other diseases of the liver code range

  Q28.2-Q28.3 Arteriovenous malformation of cerebral vessels code range
  Q28.8 Other specified congenital malformations of circulatory system
ICD-10-PCS (effective 10/01/15)  

ICD-10-PCS codes are only used for inpatient services.

  B330Y0Z, B330YZZ, B330ZZZ, B335Y0Z, B335YZZ, B335ZZZ, B338Y0Z, B338YZZ, B338ZZZ, B33GY0Z, B33GYZZ, B33GZZZ, B33QY0Z, B33QYZZ, B33QZZZ, B33RY0Z, B33RYZZ, B33RZZZ

Imaging, upper arteries, magnetic resonance imaging, code by body part, contrast (other contrast or none) and qualifier (enhanced or not)

  B430Y0Z, B430YZZ, B430ZZZ, B431Y0Z, B431YZZ, B431ZZZ, B434Y0Z, B434YZZ, B434ZZZ, B438Y0Z, B438YZZ, B438ZZZ, B43CY0Z, B43CYZZ, B43CZZZ, B43FY0Z, B43FYZZ, B43FZZZ, B43GY0Z, B43GYZZ, B43GZZZ, B43HY0Z, B43HYZZ, B43HZZZ Imaging, lower arteries, magnetic resonance imaging, code by body part, contrast (other contrast or none) and qualifier (enhanced or not)
   BW30Y0Z, BW30YZZ, BW30ZZZ, BW38Y0Z, BW38YZZ, BW38ZZZ, BW3FY0Z, BW3FYZZ. BW3FZZZ, BW3GY0Z, BW3GYZZ, BW3GZZZ

Imaging, anatomical regions, magnetic resonance imaging, code by body part, contrast (other contrast or none) and qualifier (enhanced or not)

Type of Service Radiology  
Place of Service Inpatient/Outpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

11/18/2019 

Annual review, updating verbiage regarding combination neck MRA/brain MRI. 

11/07/2019 

Annual review, updating verbiage regarding combination neck MRA/brain MRI. 

11/27/2018 

Annual review, updating criteria for neck MRA, abdomen MRA and pelvis MRA. No other changes 

11/21/2017 

Reformatting policy verbiage for clarity and specificity. Updating references.

06/14/2017 

Annual review, no change to policy intent. 

06/16/2016 

Annual review, no change to policy intent. 

06/25/2015

Annual review, no change to policy intent. Added coding.

06/18/2014

Annual review, language added to policy verbiage related to screening for aneurysm in intracranial vscular disease portion of the policy. No other changes made.


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