Description

CMR

• CMR is an imaging modality used to assess cardiac or vascular anatomy, function, perfusion, and tissue characteristics in a single examination. In lesions affecting the right heart, CMR provides excellent visualization and volume determination regardless of RV shape. This is particularly useful in patients with congenital heart disease
• CMR Safety:^16,17,18,19 Since many cardiac patients have cardiac implanted electrical devices, the risk of CMR to the patient and the device must be weighed against the benefit to the patient in terms of clinical value in optimal management.

Cardiac magnetic imaging (CMR) is often required when transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) provide inadequate imaging data.

Stress CMR for assessment of coronary artery disease (CAD) is performed pharmacologically either as:

• Vasodilator perfusion imaging with gadolinium contrast; OR
• Dobutamine inotropic wall motion (ventriculography)

With respect to CAD evaluation, since CMR is only pharmacologic (non-exercise stress), and stress echocardiography (SE) or myocardial perfusion imaging (MPI) provide similar information about CAD:

• Requests for stress CMR require diversion to exercise SE first, and to exercise MPI second.
• Exemptions for the diversion to SE or exercise MPI:
  • If body habitus or marked obesity (e.g., BMI ≥ 40) would interfere significantly with imaging with SE and MPI20
  • Evaluation of young (< 55 years old) patients with documented complex CAD, who are likely to need frequent non-invasive coronary ischemia evaluation and/or frequent radiation exposure from other testing²¹
     

OVERVIEW
CMR in CORONARY ARTERY DISEASE (CAD)^12,22,23

Stable patients without known CAD fall into 2 categories:^12,22,23

• Asymptomatic, for whom global risk of CAD events can be determined from coronary risk factors, using calculators available online
• Symptomatic, for whom we estimate the pretest probability that their chest-related symptoms are due to clinically significant (≥ 50%) CAD (below):

The 3 Types of Chest Pain or Discomfort

• Typical angina (definite) is defined as including all 3 characteristics:
  • Substernal chest pain or discomfort with characteristic quality and duration
  • Provoked by exertion or emotional stress
  • Relieved by rest and/or nitroglycerine
• Atypical angina (probable) has only 2 of the above characteristics
• Nonanginal chest pain/discomfort has only 0 – 1 of the above characteristics

The medical record should provide enough detail to establish the type of chest pain. From those details, The Pretest Probability of obstructive CAD is estimated from the Diamond Forrester Table below, recognizing that in some cases multiple additional coronary risk factors could increase pretest probability.¹²

• Very low: < 5% pretest probability of CAD, usually not requiring stress evaluation²²
• Low: 5 – 10% pretest probability of CAD
• Intermediate: 10% – 90% pretest probability of CAD
• High: > 90% pretest probability of CA

For additional information on stress imaging, please refer to NIA guideline CG 024 Myocardial Perfusion Imaging (aka Nuclear Cardiac Imaging Study).

Abbreviations
ARVD/C    Arrhythmogenic right ventricular dysplasia/cardiomyopathy ASD    Atrial septal defect
CABG       Coronary artery bypass grafting surgery CAD    Coronary artery disease
CMR         Cardiac magnetic resonance (imaging) CT    Computed tomography
ECG         Electrocardiogram
EF            Ejection fraction
HCM         Hypertrophic cardiomyopathy
ICD           Implantable cardioverter-defibrillator
LAA           Left atrial appendage
LBBB        Left bundle-branch block
LGE          Late gadolinium enhancement
LV            Left ventricle
LVH          Left ventricular hypertrophy
LVOT        Left ventricular outflow
MPI          Myocardial perfusion imaging
MR           Mitral regurgitation
MR(I)       Magnetic resonance (imaging)
PA           Pulmonary artery
PET         Positron emission tomography
PFO         Patent foramen ovale
PS           Pulmonary stenosis
RV           Right ventricle
SCD         Sudden cardiac death
SE           Stress echocardiography
SRT         Septal reduction therapy
TAVR       Transcatheter Aortic Valve Replacement

TTE         Transthoracic Echo
TEE         Transesophageal Echo
VT           Ventricular tachycardia

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.
 

Policy
INDICATIONS FOR CARDIAC MAGNETIC RESONANCE (CMR)

Cardiomyopathy and Heart Failure^1,2,3

• To assess systolic and diastolic function in the evaluation of a newly diagnosed cardiomyopathy
• Suspected infiltrative disease such as amyloidosis, sarcoidosis4, hemochromatosis, or endomyocardial fibrosis if PET has not been performed
• Suspected inherited or acquired cardiomyopathy
• Diagnosis of acute myocarditis, with suspicion based upon new, unexplained findings such as:
  • Rise in troponin not clearly due to acute myocardial infarction
  • Change in ECG suggesting acute myocardial injury or pericarditis, without evident myocardial infarction
• Assessment of hypertrophic cardiomyopathy⁵
  • When TTE is inadequate for diagnosis, management or operative planning, or when tissue characterization (degree of fibrosis) will impact indications for ICD
  • For patients with LVH when there is a suspicion of alternative diagnoses, including infiltrative or storage disease as well as athlete’s heart
  • For patients who are not otherwise as high risk for SCD, in whom the decision to proceed with an ICD is uncertain after assessment (which includes personal/family history, echocardiography), and CMR imaging is beneficial to assess for maximum LV wall thickness, ejection fraction (EF), LV apical aneurysm, and extent of myocardial fibrosis with LGE
  • For patients with obstructive HCM in whom the autonomic mechanism of obstruction is inconclusive on echocardiography, CMR is indicated for selection and planning of SRT (septal reduction therapy)
  • For patients with HCM, repeat imaging on a periodic basis (every 3-5 years) for the purpose of SCD risk stratification to evaluate changes in LGE, EF, development of apical aneurysm or LV wall thickness
• Arrhythmogenic right ventricular cardiomyopathy to aid in identification and diagnosis (assessment of myocardial fat, fibrosis, and RV tissue characteristics), based upon reason for suspicion, such as:
  • Nonsustained ventricular tachycardia (VT)
  • Unexplained syncope
  • ECG abnormalities
  • First-degree relatives with positive genotype for ARVD
• Noncompaction cardiomyopathy to aid in the diagnosis (measurement of compacted to noncompacted myocardium) when TTE is suggestive
• Clinical symptoms and signs consistent with a cardiac diagnosis known to cause presyncope/syncope (including, but not limited to, hypertrophic cardiomyopathy)
• Pulmonary hypertension in the absence of severe valvular disease

Valvular Heart Disease

• Evaluation of valvular stenosis, regurgitation, or valvular masses when transthoracic echocardiography (TTE) is inadequate⁶
• Pre-TAVR assessment if the patient has not undergone cardiac CT⁷
• Prior to transcatheter mitral valve intervention, when TTE and TEE result in uncertain assessment of the severity of mitral regurgitation^{8, 9}
• Suspected clinically significant bioprosthetic valvular dysfunction and inadequate images from TTE and TEE⁶

Evaluation of Intra- and Extra-Cardiac Structures

• Initial evaluation of cardiac mass, suspected tumor or thrombus, or potential cardiac source of emboli
• Re-evaluation of intracardiac mass when findings would change therapy
• Evaluation of pericardial disease to provide structural and functional assessment and differentiate constrictive vs restrictive physiology
• Assessment of left ventricular pseudoaneurysm, when TTE was inadequate
• Identification and characteristics of coronary aneurysms or anomalous coronary arteries

Pre-Procedure Evaluation for Closure of ASD or PFO

• For assessment of atrial septal anatomy and atrial septal aneurysm
• For assessment of suitability for percutaneous device closure

Assessment Following LAA Occlusion

• For surveillance at 45 days or FDA guidance, if TEE or Heart CT was not done, to assess:
  • Device stability
  • Device leaks
  • To exclude device migration

Pre-Ablation Planning
•    Evaluation of left atrium and pulmonary veins prior to radiofrequency ablation for atrial fibrillation, if cardiac CT has not been done

Aortic Pathology

• CT, MR, or echocardiogram can be used for screening and follow-up, with CT and MR preferred for imaging beyond the proximal ascending thoracic aorta
• Screening of first-degree relatives with a history of thoracic aortic aneurysm or dissection
• Six-month follow-up after initial diagnosis of thoracic aortic aneurysm to measure rate of change
• Annual follow-up for an enlarged thoracic aortic aneurysm (usually defined as > 4.4.cm)
• Biannual (2x/year) follow-up of enlarged aortic root or showing growth rate ≥ 0.5 cm/year
• Screening of first-degree relative with a bicuspid aortic valve
• Re-evaluation (< 1 y) of the size and morphology of the aortic sinuses and ascending aorta in patients with a bicuspid AV and an ascending aortic diameter > 4 cm with 1 of the following:
  • Aortic diameter > 4.5 cm
  • Rapid rate of change in aortic diameter
  • Family history (first-degree relative) of aortic dissection
• Patients with Turner’s syndrome annually if an abnormality exists; if initial study normal, can have imaging every 5 – 10 years¹⁰
• Evaluation in patients with known or suspected connective tissue disease or genetic condition that predispose to aortic aneurysm or dissection, such as Marfan syndrome, Ehlers-Danlos or Loeys-Dietz syndrome (at the time of diagnosis and 6 months thereafter), followed by annual imaging (can be done more frequently if > 4.5 cm or rate of growth > 0.5 cm/year- up to twice per year)

Congenital Heart Disease (CHD)¹¹

• For all indications below, either CT or CMR can be done
• All lesions: evaluation prior to planned repair and evaluation for change in clinical status and/or new concerning signs or symptoms
• Patent Ductus Arteriosus: routine surveillance (1 – 2 years) in a patient with postprocedural aortic obstruction
• Eisenmenger Syndrome and Pulmonary Hypertension associated with CHD:
  • Evaluation due to change in pulmonary arterial hypertension-targeted therapy
  • Initial evaluation with suspicion of pulmonary hypertension following CHD surgery
• Aortic Stenosis or Regurgitation:
  • Routine surveillance (6 – 12 months) in a child with aortic sinus and/or ascending aortic dilation with increasing size
  • Routine surveillance (2 – 3 years) in a child with aortic sinus and/or ascending aortic dilation with stable size (CMR only)
• Aortic Coarctation and Interrupted Aortic Arch:
  • Routine surveillance (3 – 5 years) in a child or adult with mild aortic coarctation
  • Post procedure (surgical or catheter-based) routine surveillance (3 – 5 years) in an asymptomatic patient to evaluate for aortic arch aneurysms, in-stent stenosis, stent fracture, or endoleak
• Coronary anomalies
• Tetralogy of Fallot:
  • Postoperative routine surveillance (2 – 3 years) in a patient with pulmonary regurgitation and preserved ventricular function (CMR only)
  • Routine surveillance (2 – 3 years) in an asymptomatic patient with no or mild sequelae (CMR only)
  • Routine surveillance (2 – 3 years) in a patient with valvular or ventricular dysfunction, right ventricular outflow tract obstruction, branch pulmonary artery stenosis, arrhythmias, or presence of an RV-to-PA conduit
• Double Outlet Right Ventricle: Routine surveillance (3 – 5 years) in an asymptomatic patient with no or mild sequelae (CMR only)
• D-Loop Transposition of the Great Arteries (postoperative):
  • Routine surveillance (3 – 5 years) in an asymptomatic patient
  • Routine surveillance (1 – 2 years) in a patient with dilated aortic root with increasing size, or aortic regurgitation
  • Routine surveillance (3 – 12 months) in a patient with ≥moderate systemic AV valve regurgitation, systemic RV dysfunction, LVOT obstruction, or arrhythmias
• Congenitally Corrected Transposition of the Great Arteries:
  • Unrepaired: routine surveillance (3 – 5 years) in an asymptomatic patient
  • Postoperative: routine surveillance (3 – 5 years) in an asymptomatic patient
  • Postoperative anatomic repair: routine surveillance (6 – 12 months) in a patient with valvular or ventricular dysfunction, right or left ventricular outflow tract obstruction, or presence of an RV-to-PA conduit
  • Postoperative physiological repair with VSD closure and/or LV-to-PA conduit: routine surveillance (3 – 12 months) in a patient with ≥ moderate systemic AV valve regurgitation, systemic RV dysfunction, and/or LV-to-PA conduit dysfunction
• Truncus Arteriosus: routine surveillance (1 – 2 years) in an asymptomatic child or adult with ≥ moderate truncal stenosis and/or regurgitation
• Single-Ventricle Heart Disease:
  • Postoperative routine surveillance (1 – 2 years) in an asymptomatic patient
  • Routine surveillance (1 – 2 years) in an asymptomatic adult postoperative Stage 2 palliation (CMR only)
• Ebstein’s anomaly and Tricuspid Valve dysplasia (only CMR indicated):
  • Evaluation prior to planned repair and evaluation for change in clinical status and/or new concerning signs or symptoms
• Pulmonary Stenosis (only CMR indicated)
  • Unrepaired: routine surveillance (3 – 5 years) in an asymptomatic adult with PS and pulmonary artery dilation
  • Postprocedural (surgical or catheter-based): routine surveillance (1 – 3 years) in an asymptomatic adult with moderate or severe sequelae
• Pulmonary Atresia (postprocedural complete repair): routine surveillance (1 – 3 years) in an asymptomatic adult with ≥ moderate sequelae

Coronary Artery Disease Evaluation (CMR as an alternative to pharmacologic MPI)
CMR, which is done pharmacologically, is used for the assessment of coronary artery disease, and can be performed if the patient would otherwise be a candidate for a pharmacologic MPI:

• If the patient can walk and is having an MPI for another reason (LBBB, CABG, etc.), MPI is chosen over CMR
• Assessment of LV wall motion to identify patients with akinetic segments that would benefit from coronary revascularization
• To identify the extent and location of myocardial necrosis in patients with chronic or acute ischemic heart disease
• Follow-up of known CAD
• Coronary stenosis of unclear significance on previous coronary angiography^3,12
• To diagnose microvascular dysfunction in patients with persistent stable anginal chest pain with suspected ischemia and nonobstructive coronary artery disease (INOCA) as documented in provider notes (no MPI diversion required).¹³

References 

1. Doherty JU, Kort S, Mehran R, et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons. J Am Coll Cardiol. Feb 5 2019;73(4):488-516. doi:10.1016/j.jacc.2018.10.038
2. Patel MR, White RD, Abbara S, et al. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: a joint report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J Am Coll Cardiol. May 28 2013;61(21):2207-31. doi:10.1016/j.jacc.2013.02.005
3. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. May 3 2022;145(18):e876-e894. doi:10.1161/cir.0000000000001062
4. Birnie DH, Sauer WH, Bogun F, et al. HRS expert consensus statement on the diagnosis and management of arrhythmias associated with cardiac sarcoidosis. Heart Rhythm. Jul 2014;11(7):1305-23. doi:10.1016/j.hrthm.2014.03.043
5. Ommen SR, Mital S, Burke MA, et al. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. Dec 22 2020;76(25):e159-e240. doi:10.1016/j.jacc.2020.08.045
6. Doherty JU, Kort S, Mehran R, Schoenhagen P, Soman P. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. Sep 26 2017;70(13):1647-1672. doi:10.1016/j.jacc.2017.07.732
7. Otto CM, Kumbhani DJ, Alexander KP, et al. 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. Mar 14 2017;69(10):1313-1346. doi:10.1016/j.jacc.2016.12.006
8. Bonow RO, O'Gara PT, Adams DH, et al. 2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. May 5 2020;75(17):2236-2270. doi:10.1016/j.jacc.2020.02.005
9. Wunderlich NC, Beigel R, Ho SY, et al. Imaging for Mitral Interventions: Methods and Efficacy. JACC Cardiovasc Imaging. Jun 2018;11(6):872-901. doi:10.1016/j.jcmg.2018.02.024
10. Isselbacher EM, Preventza O, Black JH, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146(24):e334- e482. doi:doi:10.1161/CIR.0000000000001106
11. Sachdeva R, Valente AM, Armstrong AK, et al. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease: A Report of the American College of Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol. Feb 18 2020;75(6):657-703. doi:10.1016/j.jacc.2019.10.002
12. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. Feb 4 2014;63(4):380-406. doi:10.1016/j.jacc.2013.11.009
13. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. Nov 30 2021;78(22):e187-e285. doi:10.1016/j.jacc.2021.07.053
14. Authority WSHC. Health Technology Clinical Committee FINAL Findings and Decision: Cardiac Magnetic Resonance Angiography (CMRA). June 20, 2023 Updated March 18, 2022. Accessed June 1, 2023. https://www.hca.wa.gov/assets/program/cmra-final-findings-and- decision-2022-03-18.pdf
15. Pennell DJ. Cardiovascular magnetic resonance. Circulation. Feb 9 2010;121(5):692-705. doi:10.1161/circulationaha.108.811547
16. Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. Aug 2013;34(29):2281-329. doi:10.1093/eurheartj/eht150
17. Indik JH, Gimbel JR, Abe H, et al. 2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices. Heart Rhythm. Jul 2017;14(7):e97-e153. doi:10.1016/j.hrthm.2017.04.025
18. Nazarian S, Hansford R, Rahsepar AA, et al. Safety of Magnetic Resonance Imaging in Patients with Cardiac Devices. N Engl J Med. Dec 28 2017;377(26):2555-2564. doi:10.1056/NEJMoa1604267
19. Russo RJ, Costa HS, Silva PD, et al. Assessing the Risks Associated with MRI in Patients with a Pacemaker or Defibrillator. N Engl J Med. Feb 23 2017;376(8):755-764. doi:10.1056/NEJMoa1603265
20. Shah RV, Heydari B, Coelho-Filho O, et al. Vasodilator stress perfusion CMR imaging is feasible and prognostic in obese patients. JACC Cardiovasc Imaging. May 2014;7(5):462-72. doi:10.1016/j.jcmg.2013.11.011
21. Hirshfeld JW, Jr., Ferrari VA, Bengel FM, et al. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways Developed in Collaboration With Mended Hearts. Catheter Cardiovasc Interv. Aug 1 2018;92(2):203-221. doi:10.1002/ccd.27660
22. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. Dec 18 2012;126(25):e354-471. doi:10.1161/CIR.0b013e318277d6a0
23. Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. Oct 2013;34(38):2949-3003. doi:10.1093/eurheartj/eht296

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, Blue Cross 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.

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