Lower Extremity MRI (Foot, Ankle, Knee, Leg or Hip MRI) - CAM 721HB


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.

(Plain radiographs must precede MRI evaluation)

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
Joint or muscle pain without positive findings on an orthopedic exam as listed below and , after X-ray completed1,2,3 (does not apply to young children).

  • Persistent joint or musculotendinous pain unresponsive to conservative treatment*, within the last 6 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 approvable provocative orthopedic examination tests and suspected injuries4

Note: With a positive orthopedic sign, an initial X-ray is always preferred, however, it is not required to approve advanced imaging UNLESS otherwise specified in bold below. Any test that suggests joint instability requires further imaging (list is not all inconclusive).


  • Syndesmotic injury (high ankle injury) with tenderness to palpation over the syndesmosis (AITFL — anterior inferior tibiofibular ligament) and any of the following:
    • Positive stress X-rays
    • Squeeze test
    • Cotton test
    • Dorsiflexion external rotation test.
  • Unstable lateral injury to ATFL (anterior talofibular ligament) with suspicion of a possible associated fracture around the ankle or a possible osteochondral injury of the talus AFTER non-diagnostic or inconclusive X-rays and any ONE of the following:
    • Positive stress X-rays
    • Positive anterior drawer test
    • Positive posterior drawer test
  • Achilles tendon tear
    • Thompson test


  • Anterior cruciate ligament (ACL) Injury
    • Positive testing:
      • Anterior drawer
      • Lachman’s
      • Pivot shift test
  • Suspected ACL rupture — acute knee injury with physical exam limited by pain and swelling AFTER initial X-ray completed13,14
    • Based on mechanism of injury, i.e., twisting, blunt force
      • Normal X-ray:
    • Extreme pain, inability to stand, audible pop at time of injury, very swollen joint
    • Abnormal X-ray:
      • Large joint effusion on X-ray knee effusion
  • Acute mechanical locking of the knee not due to guarding15
  • Meniscal injury/tear (A positive test is denoted by pain or audible/palpable clunk)
    • McMurray’s Compression
    • Apley’s
    • Thessaly test
  • Patellar dislocation (acute or recurrent)
    • Positive patellofemoral apprehension test
    • Radiographic findings compatible with a history of patellar dislocation (i.e., lipohemarthrosis or osteochondral fracture)
  • Posterior cruciate ligament (PCL) injury
    • Posterior drawer
    • Posterior tibial sag (Godfrey or step-off test)
  • Medial collateral ligament tear
    • Positive valgus stress testing/laxity
  • Lateral Collateral ligament tear
    • Positive Varus stress testing/laxity


  • Femoroacetabular impingement (FAI)/Labral tear
    • Anterior Impingement sign (aka FADIR test)16,17,18
    • Posterior Impingement sign (Pain with hip extension and external rotation on exam)19
    • Persistent hip mechanical symptoms (after initial radiographs completed) including clicking, locking, catching, giving way or hip instability with a clinical suspicion of labral tear and/or radiographic findings suggestive of FAI (i.e., cross over sign/pistol grip deformity) and suspected labral tear
    • To determine candidacy for hip preservation surgery for known FAI20

NOTE: For evaluation of both hips when the patient meets hip MRI guidelines (X-ray + persistent pain unresponsive to conservative treatment) for both the right and left hip, Pelvis MRI is the preferred study.

  • If labral tear is suspected and fulfills above criteria, then bilateral hip MRIs are the preferred studies (not pelvis MRI).
  • If bilateral hip arthrograms are requested and otherwise meet guidelines, bilateral hip MRIs are the preferred studies (not pelvis MRI).

Tendon Rupture After X-Ray21,22,23,24 (not listed in above)

  • High clinical suspicion of specific tendon rupture based on mechanism of injury and physical findings (i.e., palpable defect in quadriceps or patellar tendon rupture)

Bone Fracture

  • Hip and Femur
    • Suspected occult, stress or insufficiency fracture with a negative or non-diagnostic initial X-ray:25
      • Approve an immediate MRI (no follow up radiographs required) — MRI preferred test
    • Suspicion of a hip fracture in a pregnant patient does not require an initial X-ray
  • Non-hip extremities: Suspected occult, stress, or insufficiency fracture
    • If X-rays, taken 10 – 14 days after the injury or clinical assessment, are negative or non-diagnostic26
    • If at high risk for a complete fracture with conservative therapy (e.g., navicular bone), then immediate MRI is warranted27
  • Pathologic or concern for impending fracture on X-ray or CT28 — approve immediate MRI
  • Suspected ligamentous/tendon injury with known fractures on X-ray/CT that may require surgery
  • 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 study29

Osteochondral lesions (defects, fractures, osteochondritis dissecans) and X-ray completed8,30,31,32

  • Clinical suspicion based on mechanism of injury and physical findings

Joint prosthesis/replacement

  • Suspected joint prosthesis loosening or dysfunction, (i.e., pseudotumor formation) after initial X-rays33,34
  • Suspected Metallosis with painful metal on metal hip replacement after initial X-rays

Extremity Mass35

  • Mass or lesion after non-diagnostic x-ray or ultrasound.36 CT is better than MRI to evaluate mass calcification or bone involvement and may complement or replace MRI37
    • Baker’s cyst should be initially evaluated with ultrasound
    • If superficial mass, then ultrasound is the initial study
    • If deep mass, then X-ray is the initial study
  • Vascular malformations
    • After initial evaluation with ultrasound and results will change management
    • Inconclusive ultrasound
    • For preoperative planning
    • MRA is also approvable
    • Follow up after treatment/embolization

Known Primary Cancer of the Extremity38,39,40,41,42

  • 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 (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)

Osteonecrosis (e.g., avascular necrosis [AVN], Legg-Calve-Perthes Disease)43,44,45

  • To further characterize a prior abnormal x-ray or CT suggesting osteonecrosis
  • Normal or indeterminate X-rays, but symptomatic and high risk (such as glucocorticosteroid use, renal transplant, glycogen storage disease, alcohol abuse, sickle cell anemia)46
  • Known osteonecrosis to evaluate a contralateral joint after initial X-rays

Loose bodies or synovial chondromatosis and after X-ray or ultrasound completed

  • In the setting of joint pain or mechanical symptoms47,48

Infection of bone, joint, or soft tissue abscess49,50,51

  • 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 include:
      • 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, warm, swelling, pain, discharge which may range from white to serosanguineous) that is not improving despite treatment and bone, or deep infection is suspected
    • Increased suspicion if size or temperature increases, bone is exposed/positive probe-to-bone test, new areas of breakdown, new smell52
  • Neuropathic foot with friable or discolored granulation tissue, foul odor, non-purulent discharge, and delayed wound healing53

Pre-operative/procedural evaluation

  • Pre-operative evaluation for a planned surgery or procedure 

Post-operative/procedural evaluation 

  • When imaging, physical or laboratory findings indicate joint infection, delayed or non-healing or other surgical/procedural complications.
  • Trendelenburg sign54 or other indication of muscle or nerve damage after recent hip surgery

For evaluation of known or suspected autoimmune disease (e.g., rheumatoid arthritis)55

  • 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 of the following:
    • Early rheumatoid arthritis
    • Advanced rheumatoid arthritis if X-ray and ultrasound are equivocal or noncontributory

Known or suspected inflammatory myopathies: (Includes polymyositis, dermatomyositis, immune-mediated necrotizing myopathy, inclusion body myositis)56,57

  • For diagnosis
  • For biopsy planning

Peripheral nerve entrapment (e.g., tarsal tunnel, Morton’s neuroma)58,59,60,61

  • 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

Foreign body62

  • Indeterminate X-ray and ultrasound

Painful acquired or congenital flatfoot deformity in an adult, after X-ray completed
After failure of active conservative therapy listed above63,64

Special pediatric considerations

  • Painful flatfoot deformity with suspected tarsal coalition, not responsive to active conservative care65
  • Slipped Capital Femoral Epiphysis with negative frog leg and AP x-rays of the hips but clinically suspected66,67,68
    • Drehmann sign
    • Limited internal rotation of the hip
    • Consider imaging the asymptomatic contralateral hip with a normal x-ray to detect early SCFE if prophylactic surgery is planned69
  • Chronic recurrent multifocal osteomyelitis after initial work-up (labs (i.e. CRP/ESR and x-ray)70,71 (Whole body bone marrow MRI is more appropriate when multiple  joints requested see NIA_CG_059)
  • Acute limp in a child 5 or less years old
    • Concern for infection not localized to the hip (initial imaging not required)72
    • Concern for infection localized to the hip after initial evaluation with ultrasound72
  • Osteoid Osteoma — MRI not usually done because X-ray and CT more accurate for diagnosis73

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. MRI can positively influence clinicians’ diagnoses and management plans for patients with conditions such as primary bone cancer, fractures, abnormalities in ligaments/tendons/cartilage, septic arthritis, and infection/inflammation.

*Conservative therapy — (Musculoskeletal) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components such as rest, ice, heat, modified activities, medical devices, (including crutches, immobilizer, metal braces, orthotics, rigid stabilizer, or splints, etc. and not to include neoprene sleeves), medications, injections (bursal, and/or joint, not including trigger point), and diathermy, can be utilized. Active modalities may consist of physical therapy, a physician supervised home exercise program**, and/or chiropractic care. 

**Home exercise program (HEP) — The following two elements are required to meet guidelines for completion of conservative therapy:

  • Information provided on exercise prescription/plan AND
  • Follow-up with member with information provided regarding completion of HEP (after suitable 4-week period), or inability to complete HEP due to physical reason- i.e., increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without explanation does not constitute “inability to complete” HEP).

American Academy of Pediatrics “Choosing Wisely” Guidelines advise against ordering advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory and plain radiographic examinations have been completed. “History, physical examination, and appropriate radiographs remain the primary diagnostic modalities in pediatric orthopedics, as they are both diagnostic and prognostic for the great majority of pediatric musculoskeletal conditions. Examples of such conditions would include, but not be limited to, the work up of injury or pain (spine, knees and ankles), possible infection, and deformity. MRI examinations and other advanced imaging studies frequently require sedation in the young child (5 years old or less) and may not result in appropriate interpretation if clinical correlations cannot be made. Many conditions require specific MRI sequences or protocols best ordered by the specialist who will be treating the patient … if you believe findings warrant additional advanced imaging, discuss with the consulting orthopedic surgeon to make sure the optimal studies are ordered.”74 


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Coding Section 






Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; without contrast material(s)



with contrast material(s)



without contrast material(s), followed by contrast material(s) and further sequences



Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material



with contrast material(s) 



without contrast material(s), followed by contrast material(s) and further sequences

  0698T Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, multiple organs

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 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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