GENERAL INFORMATION
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes,  laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Purpose
MRA/MRV
Magnetic resonance angiography (MRA) and (MRV) generates images of the blood vessels that can be evaluated for evidence of stenosis, occlusion, or aneurysms without use of ionizing radiation. It is used to evaluate the blood vessels of the lower extremities.

NOTE: Authorization for MR Angiography covers both arterial and venous imaging. The term angiography refers to both arteriography and venography.

Policy
Imaging Request
When a separate MRA and MRI exam is requested, documentation requires a medical reason that clearly indicates why additional MRI imaging of the lower extremity is needed.

INDICATIONS
Peripheral Artery Entrapment Syndrome
After abnormal arterial ultrasound and when imaging will change management¹

Deep Venous Thrombosis
Clinical suspicion of lower extremity DVT (when ultrasound is abnormal or inconclusive and a positive study would change management)^2,3,4

Clinical Suspicion of Vascular Disease
Abnormal or indeterminate ultrasound or other imaging:

• Tumor invasion^5,6
• Trauma⁷
• Vasculitis⁸
• Aneurysm⁸
• Stenosis/occlusions⁹

Hemodialysis Graft Dysfunction
After Doppler ultrasound, if findings were not adequate¹⁰ for treatment decisions¹¹

Vascular Malformation^11,12

• After initial evaluation with ultrasound if:
  • Results will change management
  • Results are inconclusive ultrasound
  • If a known or suspected high flow lesion
• For preoperative planning
  • MRI is also approvable for initial evaluation

Traumatic Injuries
Clinical findings suggestive of arterial injury (CTA preferred if emergent)

Peripheral Vascular Disease^9,13,14,15
For evaluation of known or suspected lower extremity arterial disease when CTA is contraindicated or cannot be performed:

• For known or suspected peripheral arterial disease (such as claudication, or clinical concern for vascular causes of ulcers) when non-invasive studies (pulse volume recording, ankle-brachial index, toe brachial index, segmental pressures, or doppler ultrasound) are abnormal or indeterminate OR
• For critical limb ischemia with ANY of the below clinical signs of peripheral artery disease (prior ultrasound is not needed; if done and negative, MRA should still be approved)^16,17
  • Ischemic rest pain
  • Tissue Loss
  • Gangrene
• After stenting or surgery with signs of recurrent symptoms, abnormal ankle/brachial index, abnormal or indeterminate arterial Doppler, or abnormal or indeterminate pulse volume recording

NOTE: As there is no CPT for MRA Aortogram with runoff, when the criteria above are met, two separate authorizations are required: Abdomen MRA (CPT 74185) and one Lower Extremity MRA (CPT 73725). This will provide imaging of the abdomen, pelvis and both legs. A separate Pelvis MRA authorization is NOT required. Only one Lower Extremity MRA is required (not two).

Evaluation of Tumor
When needed for clarification of vascular invasion from tumor after prior imaging (may be approved in combination with CT or MRI of tumor)

Pre-operative/Procedure Evaluation
Pre-operative evaluation for a planned surgery or procedure¹³

Post-operative/Procedure Evaluation
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.^18,19

Further Evaluation of Indeterminate Findings on Prior Imaging
Unless follow-up is otherwise specified within the guideline

• For initial evaluation of an inconclusive finding on a prior imaging report (i.e., X-ray, ultrasound or CT) that requires further clarification
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam.)

Genetics and Rare Diseases

• Known vascular EDS (vEDS) with acute extremity pain and concern for dissection/rupture^20,21
• Vascular EDS (vEDS) surveillance imaging: with inconclusive ultrasound or ultrasound suggestive of vascular pathology^20,21
• Known Williams Syndrome: when there is concern for vascular disease based on abnormal exam or imaging findings (such as diminished pulses, bruits or signs of diffuse thoracic aortic stenosis)²²
• For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance

Combination Studies
Abdomen MRA/Chest MRA/ and/or Lower Extremity MRA

• To evaluate for an embolic source of lower extremity vascular disease. Echocardiography is also often needed, since the heart is the most commonly reported source of lower extremity emboli, accounting for 55 to 87 percent of events

Rationale/Background
Testing
Noninvasive Testing
“Noninvasive testing (NIVT), both before and after intervention, has been used as a first-line investigatory tool in the diagnosis and categorization of PAD. It is widely available, provides a large amount of information, and is a low cost without the use of ionizing radiation."¹⁹ NIVT can consist of one or more of the following components:¹⁹

• ABI
• Segmental pressure measurements (SPMs)
• Pulse-volume recordings (PVRs)
• Photoplethysmography (PPG)
• Transcutaneous oxygen pressure measurement (TcPO2)

Noninvasive Hemodynamic Testing
The ankle-brachial index (ABI) is the ratio of systolic blood pressure at the ankle divided by the systolic pressure of the upper arm. The normal range lies between 0.9 – 1.4. An ABI of < 0.9 is a reliable indicator of the presence of lower extremity PAD, indicating atheroocclusive arterial disease. The upper limit of normal ABI should not exceed 1.40. An ABI > 1.40 is suggestive of arterial stiffening (i.e., medial arterial calcification) and is also associated with a higher risk of cardiovascular events and is seen in elderly patients, typically in those with diabetes or chronic kidney disease (CKD).

Contraindications and Preferred Studies

• Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester)
• Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as noncompatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine.

References

1. Bradshaw S, Habibollahi P, Soni J, Kolber M, Pillai A. Popliteal artery entrapment syndrome. Cardiovascular diagnosis and therapy. 2021; 11: 1159-1167. 10.21037/cdt-20-186.
2. Hanley M, Steigner M, Ahmed O, Azene E, Bennett S et al. ACR Appropriateness Criteria® Suspected Lower Extremity Deep Vein Thrombosis. Journal of the American College of Radiology. 2018; 15: S413 - S417. 10.1016/j.jacr.2018.09.028.
3. Karande G Y, Hedgire S, Sanchez Y, Baliyan V, Mishra V et al. Advanced imaging in acute and chronic deep vein thrombosis. Cardiovasc Diagn Ther. 2016; 6: 493-507. 10.21037/cdt.2016.12.06.
4. Katz D, Fruauff K, Kranz A, Hon M. Imaging of deep venous thrombosis: A multimodality overview. Applied Radiology. 2014; 6-16.
5. Garner H, Wessell D, Lenchik L, Ahlawat S, Baker J et al. ACR Appropriateness Criteria® Soft Tissue Masses: 2022 Update. Journal of the American College of Radiology : JACR. 2023; 20: S234-S245. 10.1016/j.jacr.2023.02.009.
6. Jin T, Wu G, Li X, Feng X. Evaluation of vascular invasion in patients with musculoskeletal tumors of lower extremities: use of time-resolved 3D MR angiography at 3-T. Acta Radiol. 2018; 59: 586-592. 10.1177/0284185117729185.
7. Wani M L, Ahangar A G, Ganie F A, Wani S N, Wani N U. Vascular injuries: trends in management. Trauma Mon. 2012; 17: 266-9. 10.5812/traumamon.6238.
8. Seitz L, Seitz P, Pop R, Lötscher F. Spectrum of Large and Medium Vessel Vasculitis in Adults: Primary Vasculitides, Arthritides, Connective Tissue, and Fibroinflammatory Diseases. Current rheumatology reports. 2022; 24: 352-370. 10.1007/s11926-022-01086-2.
9. Conte M, Pomposelli F, Clair D, Geraghty P, McKinsey J et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. Journal of vascular surgery. 2015; 61: 2S-41S. 10.1016/j.jvs.2014.12.009.
10. Richarz S, Isaak A, Aschwanden M, Partovi S, Staub D. Pre-procedure imaging planning for dialysis access in patients with end-stage renal disease using ultrasound and upper extremity computed tomography angiography: a narrative review. Cardiovascular Diagnosis and Therapy. 2023; 13: 122-132. 10.21037/cdt-21-797.
11. Madani H, Farrant J, Chhaya N, Anwar I, Marmery H et al. Peripheral limb vascular malformations: an update of appropriate imaging and treatment options of a challenging condition. Br J Radiol. 2015; 88: 20140406. 10.1259/bjr.20140406.
12. Obara P, McCool J, Kalva S, Majdalany B, Collins J et al. ACR Appropriateness Criteria® Clinically Suspected Vascular Malformation of the Extremities. J Am Coll Radiol. 2019; 16: S340-s347. 10.1016/j.jacr.2019.05.013.
13. Azene E, Steigner M, Aghayev A, Ahmad S, Clough R et al. ACR Appropriateness Criteria® Lower Extremity Arterial Claudication-Imaging Assessment for Revascularization: 2022 Update. Journal of the American College of Radiology. 2022; 19: S364 - S373. 10.1016/j.jacr.2022.09.002.
14. Singh-Bhinder N, Kim D H, Holly B P, Johnson P T, Hanley M et al. ACR Appropriateness Criteria® Nonvariceal Upper Gastrointestinal Bleeding. Journal of the American College of Radiology. 2017; 14: S177 - S188. 10.1016/j.jacr.2017.02.038.
15. Werncke T, Ringe K, von Falck C, Kruschewski M, Wacker F. Diagnostic Confidence of Run-Off CT-Angiography as the Primary Diagnostic Imaging Modality in Patients Presenting with Acute or Chronic Peripheral Arterial Disease. PLOS ONE. 2015; 10: true. https://doi.org/10.1371/journal.pone.0119900.
16. Browne W, Sung J, Majdalany B, Khaja M, Calligaro K et al. ACR Appropriateness Criteria® Sudden Onset of Cold, Painful Leg: 2023 Update. Journal of the American College of Radiology : JACR. 2023; 20: S565-S573.
17. Shishehbor M, White C, Gray B, Menard M, Lookstein R et al. Critical Limb Ischemia: An Expert Statement. Journal of the American College of Cardiology. 2016; 68: 2002 - 2015. https://doi.org/10.1016/j.jacc.2016.04.071.
18. Conte M S, Bradbury A W, Kolh P, White J V, Dick F et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019; 69: 3S-125S.e40. 10.1016/j.jvs.2019.02.016.
19. Cooper K, Majdalany B, Kalva S, Chandra A, Collins J et al. ACR Appropriateness Criteria(®) Lower Extremity Arterial Revascularization-Post-Therapy Imaging. J Am Coll Radiol. 2018; 15: S104-s115. 10.1016/j.jacr.2018.03.011.
20. Byers P. Vascular Ehlers-Danlos Syndrome. [Updated 2019 Feb 21]. GeneReviews® [Internet]. 2019;
21. Bowen J, Hernandez M, Johnson D, Green C, Kammin T et al. Diagnosis and management of vascular Ehlers-Danlos syndrome: Experience of the UK national diagnostic service, Sheffield. European journal of human genetics : EJHG. 2023; 31: 749-760. 10.1038/s41431-023-01343-7.
22. Morris C. Williams Syndrome. [Updated 2023 Apr 13]. GeneReviews® [Internet]. 2023;

Coding Section 

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, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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

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