Description
Magnetic resonance angiography (MRA) is a noninvasive alternative to catheter angiography for evaluation of vascular structures in the upper extremity. Magnetic resonance venography (MRV) is used to image veins instead of arteries. MRA and MRV are less invasive than conventional X-ray digital subtraction angiography.

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.

OVERVIEW
Upper Extremity DVT — “Secondary UEDVT is far more common. Indwelling venous devices, such as catheters, pacemakers, and defibrillators, put patients at the highest risk of thrombus. Other risk factors include advanced age, previous thrombophlebitis, postoperative state, hypercoagulability, heart failure, cancer, right-heart procedures, intensive care unit admissions, trauma, and extrinsic compression.”⁷

MRA and Dialysis Graft — The management of the hemodialysis access is important for patients undergoing dialysis. With evaluation and interventions, the patency of hemodialysis fistulas may be prolonged. In selected cases, MRA is useful in the evaluation of hemodialysis graft dysfunction. MRA provides excellent image quality and accurately demonstrating significant stenosis with high sensitivity and specificity in the evaluation of hemodialysis graft dysfunctions.

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

Policy
UPPER EXTREMITY MRA/MRV is considered MEDICALLY NECESSARY for the following indications:

INDICATIONS
Hand Ischemia^1,2,3

• For clinical symptoms, following abnormal arterial Doppler, when MRA results will change management
  • Includes Raynaud’s (can be associated with scleroderma), Buerger disease, and other vasculopathies⁴
• Clinical concern for vascular cause of ulcers with abnormal or indeterminate ultrasound⁵
• After stenting or surgery with signs of recurrence or indeterminate ultrasound⁶

Deep Venous Thrombosis or Embolism^7,8

• After abnormal ultrasound of arm veins if it will change management
• After negative or indeterminate ultrasound to rule out other causes
• Evaluation of central veins
• Clinical suspicion of upper arterial emboli^9,10

Clinical Suspicion of Vascular Disease
Abnormal or indeterminate ultrasound or other imaging^9,10 for suspicion of:

• Tumor invasion^11,12
• Trauma¹³
• Vasculitis^2,14
• Aneurysm^11,14
• Stenosis/occlusions¹⁵

Hemodialysis Graft Dysfunction
If Doppler ultrasound was not adequate¹⁶ for treatment decisions¹⁷

Vascular Malformation^18,19

• After initial evaluation with ultrasound
• Preoperative planning

A concurrent MRI is also approvable for initial evaluation and/or preoperative planning

Traumatic Injuries
Clinical findings suggestive of arterial injury (CTA preferred emergently)¹³

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/Procedural Evaluations
Pre-operative evaluation for a planned surgery or procedure²⁰

Post-Operative/Procedural Evaluations
A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery.²¹ Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

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)

Genetic Syndrome and Rare Diseases

• For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance

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

Rationale
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 non- compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine.
   

References

1. Bae M, Chung S, Lee C, Choi J, Song S. Upper Limb Ischemia: Clinical Experiences of Acute and Chronic Upper Limb Ischemia in a Single Center. Korean J Thorac Cardiovasc Surg. 2015; 48: 246-51. 10.5090/kjtcs.2015.48.4.246.
2. Hotchkiss R, Marks T. Management of acute and chronic vascular conditions of the hand. Curr Rev Musculoskelet Med. 2014; 7: 47-52. 10.1007/s12178-014-9202-6.
3. Wong V, Major M, Higgins J. Nonoperative Management of Acute Upper Limb Ischemia. Hand (N Y). 2016; 11: 131-43. 10.1177/1558944716628499.
4. McMahan Z, Wigley F. Raynauds phenomenon and digital ischemia: a practical approach to risk stratification, diagnosis and management. Int J Clin Rheumtol. 2010; 5: 355-370. 10.2217/ijr.10.17.
5. Rosyid F. Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer. Int J Res Med Sci. 2017; 5: 4206-13. http://dx.doi.org/10.18203/2320-6012.ijrms20174548.
6. Pollak A, Norton P, Kramer C. Multimodality imaging of lower extremity peripheral arterial disease: current role and future directions. Circ Cardiovasc Imaging. 2012; 5: 797-807. 10.1161/circimaging.111.970814.
7. Desjardins B, Hanley M, Steigner M, Aghayev A, Azene E et al. ACR Appropriateness Criteria® Suspected Upper Extremity Deep Vein Thrombosis. Journal of the American College of Radiology. 2020; 17: S315 - S322. 10.1016/j.jacr.2020.01.020.
8. Heil J, Miesbach W, Vogl T, Bechstein W, Reinisch A. Deep Vein Thrombosis of the Upper Extremity. Dtsch Arztebl Int. 2017; 114: 244-249. 10.3238/arztebl.2017.0244.
9. Bozlar U, Ogur T, Khaja M, All J, Norton P. CT angiography of the upper extremity arterial system: Part 2- Clinical applications beyond trauma patients. AJR Am J Roentgenol. 2013; 201: 753-63. 10.2214/ajr.13.11208.
10. Bozlar U, Ogur T, Norton P, Khaja M, All J. CT angiography of the upper extremity arterial system: Part 1-Anatomy, technique, and use in trauma patients. AJR Am J Roentgenol. 2013; 201: 745-52. 10.2214/ajr.13.11207.
11. 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.
12. 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.
13. Wani M, Ahangar A, Ganie F, Wani S, Wani N. Vascular injuries: trends in management. Trauma Mon. 2012; 17: 266-9. 10.5812/traumamon.6238.
14. 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.
15. 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.
16. 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. 2022; 13: 122-132.
17. Murphy E, Ross R, Jones R, Gandy S, Aristokleous N et al. Imaging in Vascular Access. Cardiovasc Eng Technol. 2017; 8: 255-272. 10.1007/s13239-017-0317-y.
18. 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.
19. 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.
20. Azene E, Steigner M, Aghayev A, Ahmad S, Clough R et al. ACR Appropriateness Criteria® Lower Extremity Arterial Claudication-Imaging. Journal of the American College of Radiology : JACR. 2022; 19: S364-S373. 10.1016/j.jacr.2022.09.002.
21. Conte M, Bradbury A, Kolh P, White J, Dick F et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. Journal of vascular surgery. 2019; 69: 10.1016/j.jvs.2019.02.016.
22. 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.
23. Byers P. Vascular Ehlers-Danlos Syndrome. [Updated 2019 Feb 21]. GeneReviews® [Internet]. 2019;
24. 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 non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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