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
MRI
Magnetic resonance imaging shows the soft tissues and bones. With its multiplanar capabilities, high contrast, and high spatial resolution, it is an accurate diagnostic tool for 
conditions affecting the joint and adjacent structures. 

Special Note

• Plain radiographs must precede MRI evaluation unless otherwise indicated 
• Some indications are for MRI, CT, or MR or CT Arthrogram (more than one should not be approved at the same time)
• If an MR Arthrogram fits approvable criteria below, approve as MRI

Policy  
INDICATIONS FOR UPPER EXTREMITY MRI
Joint or Muscle Pain^1,2
Negative Findings on Orthopedic Exam and after X-Ray Completed

NOTE: Does not apply to young children (up to age 12)

• Persistent joint or musculotendinous pain unresponsive to conservative treatment*, within the last six months which includes active medical therapy (physical therapy, chiropractic treatments, and/or physician supervised exercise**) of at least four weeks
• With progression or worsening of symptoms during the course of conservative treatment

Joint Specific Provocative Exam Tests and Suspected Injuries
Approvable Orthopedic Test

With a positive orthopedic sign, an initial x-ray is always preferred; however, it is not required to approve advanced imaging. A positive sign is weakness or pain. In addition, any test that suggests joint instability requires further imaging (the below list is not all inclusive)

Shoulder³

• Rotator cuff weakness on exam
• Subscapularis tendon tear⁴
  • Belly press off test
  • Napoleon test
  • Bear Hug test
  • Internal rotation lag
  • Lift-off test
• Supraspinatus tendon tear^5,6
  • Drop Arm
  • Full Can test
  • Empty Can (aka Jobe or Supraspinatus test)
  • Hawkins or Neer test (only when ordered by an orthopedic surgeon if there is clear documentation in the records that an actual rotator cuff tear is suspected, and NOT just for the evaluation of impingement)
• Infraspinatus/Teres Minor/Biceps tendon tear⁷
  • External rotation lag sign at 0 and 90 degrees
  • Pain or weakness with resisted external rotation testing
  • Hornblower test
  • Popeye sign (if acute finding or for evaluation of surgical correction)
• Labral tear/ Instability⁸
  • Grind test
  • Clunk test
  • Crank test, Compression-rotation test
  • O’Brien’s test
  • Anterior load and shift
  • Apprehension test
  • Posterior load and shift test
  • Jerk Test
  • Sulcus sign

Elbow^9,10

• Biceps tendon¹¹
  • Bicipital aponeurosis (BA) flex test
  • Biceps squeeze test
  • Hook test
  • Passive forearm pronation test
  • Reverse Popeye sign (if acute finding or for evaluation of surgical correction)
• Instability¹²
  • Posterolateral rotatory drawer test
  • Tabletop relocation test
  • Valgus stress
  • Varus stress
  • Milking maneuver
  • Push-up test

Wrist^13,14,15

• Lunotriquetral ligament
  • Derby relocation test
  • Reagan test (lunotriquetral ballottement test)
• Triangular Fibrocartilage Complex (TFCC) tear
  • Press test
  • Ulnar foveal sign/test
  • Ulnocarpal stress test
• Scaphoid ligament
  • Watson test (scaphoid shift test)
  • Scapholunate ballottement test

Tendon or Muscle Rupture
After X-Ray and/ or ultrasound not Listed Above
High clinical suspicion of specific tendon rupture based on mechanism of injury and physical findings (i.e., triceps or pectorals tendon rupture)

Shoulder Dislocations^16,17,18,19

• Recurrent
• First time in any of the situations below that increase the risk of repeated dislocation
  • Anterior glenoid or humeral(Hill-Sachs lesion) bone loss on X-ray
  • Bony Bankart lesion on radiographs
  • 14 – 40 year-old
  • > 40 with exam findings concerning for rotator cuff tear (i.e., weakness on exam)

Bone Fracture or Ligament Injury²⁰

• Suspected occult scaphoid fracture with snuffbox pain after initial X-ray
• Non scaphoid suspected occult, stress or insufficiency fracture with a negative initial X-ray
  • Repeat X-rays in 10 – 14 days if negative or non-diagnostic
• Pathologic fracture on X-ray or CT
• Suspected ligamentous/tendon injury with known fractures on X-ray/CT that may require surgery

Fracture Nonunion²¹
Nonunion or delayed union as demonstrated by no healing between two sets of X-rays. If a fracture has not healed by 4 – 6 months, there is delayed union. Incomplete healing by 6 – 8 months is nonunion. CT is the preferred study.

Osteochondral Lesions^22,23
Defects, Fractures, Osteochondritis Dissecans
In the setting of joint pain or mechanical symptoms

NOTE: X-ray completed

Loose Bodies or Synovial Chondromatosis²⁴
After X-Ray or Ultrasound Completed
In the setting of joint pain or mechanical symptoms

Osteonecrosis²⁵
To further characterize a prior abnormal x-ray or CT suggesting osteonecrosis

• Normal X-rays but symptomatic and high-risk (e.g., glucocorticosteroid use, renal transplant recipient, glycogen storage disease, alcohol abuse, sickle cell anemia)
• Known osteonecrosis to evaluate a contralateral joint after initial X-rays 

e.g., Avascular Necrosis (AVN)

Joint Prosthesis/Replacement²⁶
Suspected joint prosthesis loosening, infection, or dysfunction, after initial X-rays

Extremity Mass²⁷

• Mass or lesion after non-diagnostic X-ray or ultrasound CT is better than MRI to evaluate mass calcification or bone involvement and may complement or replace MRI
  • Superficial mass, then ultrasound is the initial study
  • Deep mass, then X-ray is the initial study
• Vascular malformations²⁸
  • After initial evaluation with ultrasound and results will change management
  • Inconclusive ultrasound
  • Preoperative planning
    • MRA is also approvable
  • Follow-up after treatment/embolization

Known Primary Cancer of the Extremity^29,30,31,32

• Initial staging primary extremity tumor
• Follow-up of known primary cancer of patient undergoing active treatment within the past year or as per surveillance imaging guidance for that cancer
• Signs or symptoms or imaging findings suspicious for recurrence
• Suspected metastatic disease with signs/symptoms and after initial imaging with radiographs

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 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.)

Infection of Bone, Joint, or Soft Tissue Abscess³³

• Abnormal X-ray or ultrasound
• Negative X-ray or ultrasound but with a clinical suspicion of infection based on either of the following:
  • Signs and symptoms of joint or bone infection such as: 
    • Pain and swelling
    • Decreased range of motion
    • Fevers
  • Laboratory findings of infection include any of the following:
    • Elevated ESR or CRP
    • Elevated white blood cell count
    • Positive joint aspiration
• Ulcer (diabetic, pressure, ischemic, traumatic) with signs of infection (redness, warmth, swelling, pain, discharge which may range from white to serosanguineous) that is not improving despite treatment and bone, or deep infection is suspected³⁴ 
  • Increased suspicion if size or temperature increases, bone is exposed/positive probe-to-bone test, new areas of breakdown, new smell

Pre-Operative/Procedural Evaluation
Pre-operative evaluation for a planned surgery or procedure

Evaluation of Tumor
When needed for clarification of vascular invasion from tumor after prior imaging.

Post-Operative/Procedural Evaluation
When imaging, physical examination, or laboratory findings indicate joint infection, delayed or non-healing or other surgical/procedural complications.

Evaluation of Known or Suspected Autoimmune Disease

• Further evaluation of an abnormality or non-diagnostic findings on prior imaging
• Initial imaging of a single joint for diagnosis or response to therapy after plain films and appropriate lab tests (e.g., RF, ANA, CRP, ESR)
• To determine change in treatment or when diagnosis is uncertain prior to start of treatment
• Follow-up to determine treatment efficacy in the following:
  • Early rheumatoid arthritis
  • Advanced rheumatoid arthritis if X-ray and ultrasound are equivocal or non-contributory
• Known or suspected inflammatory myopathies (such as polymyositis, dermatomyositis, immune-mediated necrotizing myopathy, inclusion body myositis)
  • For diagnosis
  • For biopsy planning

e.g., Rheumatoid Arthritis

Foreign Body³⁷
Indeterminate X-ray and ultrasound

Peripheral Nerve Entrapment^38,39

• Abnormal electromyogram or nerve conduction study
• Abnormal X-ray or ultrasound
• Clinical suspicion and failed 4 weeks conservative treatment including at least two of the following (active treatment with physical therapy is not required):
  • Activity modification
  • Rest, ice, or heat
  • Splinting or orthotics
  • Medication

NOTE: e.g., carpal tunnel

Brachial Plexopathy^40,41

• Traumatic Brachial Plexopathy: If mechanism of injury is highly suspicious for brachial plexopathy (such as mid-clavicular fracture, shoulder dislocation, contact injury to the neck (burner or stinger syndrome) or penetrating injury)⁴²
• Non-traumatic Brachial Plexopathy when Electromyography/Nerve Conduction Velocity (EMG/NCV) studies are suggestive of brachial plexopathy

NOTE: Either Neck MRI, Shoulder MRI or Chest MRI may be appropriate depending on the location of the injury/plexopathy. Only ONE of these three studies is indicated.

Pediatrics (Up to Age 18)

• Chronic Recurrent Multifocal Osteomyelitis after initial work-up (labs (i.e., CRP/ESR and X-ray)^43,44
  • Whole-body Bone Marrow MRI is more appropriate when multiple joints requested, see CAM 735 Bone Marrow MRI

Contraindication 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 weight limit/dimensions of MRI machine

References

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2. Pieters L, Lewis J, Kuppens K, Jochems J, Bruijstens T et al. An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain. J Orthop Sports Phys Ther. 2020; 50: 131-141. 10.2519/jospt.2020.8498. 
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6. Katepun S, Boonsun P, Boonsaeng W, Apivatgaroon A. Reliability of the Single-Arm and Double-Arm Jobe Test for the Diagnosis of Full-Thickness Supraspinatus Tendon Tear. Orthopaedic Journal of Sports Medicine. 2023; 11: 10.1177/23259671231187631. 
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13. Margulies I, Xu H, Gopman J, Freeman M, Dayan E et al. Narrative Review of Ligamentous Wrist Injuries. Journal of hand and microsurgery. 2021; 13: 55-64. 10.1055/s-0041-1724224. 
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18. Tupe R, Tiwari V. Anteroinferior Glenoid Labrum Lesion (Bankart Lesion). [Updated 2023 Aug 3]. StatPearls Publishing. 2023; https://pubmed.ncbi.nlm.nih.gov/36508533/. 
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21. Thomas J, Kehoe J. Bone Nonunion. [Updated 2023 Mar 6]. StatPearls Publishing. 2023; https://www.ncbi.nlm.nih.gov/books/NBK554385/. Anderson M, Chung C. Elbow Imaging with an Emphasis on MRI. IDKD Springer Series. Springer, Cham Musculoskeletal Diseases 2021-2024. 2021; 23 - 39. 10.1007/978-3-030-71281-5_3. 
22. van Bergen C J, van den Ende K I, Ten Brinke B, Eygendaal D. Osteochondritis dissecans of the 
23. capitellum in adolescents. World J Orthop. 2016; 7: 102-8. 10.5312/wjo.v7.i2.102. 
24. Habusta S, Mabrouk A, Tuck J. Synovial Chondromatosis. [Updated 2023 Apr 22]. StatPearls Publishing. 2023; https://www.ncbi.nlm.nih.gov/books/NBK470463/. 
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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.

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

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