Aetna · Clinical coverage policy

Aetna Cardiac MRI coverage criteria

Aetna CPB 0520 covers cardiac MRI / MR angiography of the cardiovascular system as medically necessary only for a defined list of conditions — including thoracic aortic disease, pericardial disease, congenital heart disease, coronary artery disease (as a substitute for, not in addition to, SPECT), cardiomyopathy, myocarditis, anomalous coronary arteries, and diseases of the large veins — with several indications (cardiac function/morphology, valvular disease, atrial-appendage thrombus, cardiac masses) gated on echocardiography/Doppler being inconclusive or expected to be non-diagnostic. Numerous uses (e.g., 4D-flow MRI, whole-heart coronary MRA/MRI, ferumoxytol-enhanced cMRI, screening, transplant-rejection, ventricular-arrhythmia prediction) are experimental/investigational, and any indication not on the list is subject to medical review.

Policy CPB 0520 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0520

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0520 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Cardiac MRI (CPT 75557), and what gets it denied?

Path
Aetna CPB 0520 covers cardiac MRI / MR angiography of the cardiovascular system as medically necessary only for a defined list of conditions — including thoracic aortic disease, pericardial disease, congenital heart disease, coronary artery disease (as a substitute for, not in addition to, SPECT), cardiomyopathy, myocarditis, anomalous coronary arteries, and diseases of the large veins — with several indications (cardiac function/morphology, valvular disease, atrial-appendage thrombus, cardiac masses) gated on echocardiography/Doppler being inconclusive or expected to be non-diagnostic. Numerous uses (e.g., 4D-flow MRI, whole-heart coronary MRA/MRI, ferumoxytol-enhanced cMRI, screening, transplant-rejection, ventricular-arrhythmia prediction) are experimental/investigational, and any indication not on the list is subject to medical review. Coverage criteria include: Thoracic aortic disease (for example): abnormal aortic contour or size on chest X-ray; differentiation of mediastinal mass versus vascular abnormality; to rule out aortic dissection; aneurysm; leaking thoracic aneurysm; exclude aortic source of peripheral embolization; Sinus of Valsalva aneurysm; Marfan's syndrome and aortic annular ectasia; after therapy of aortic dissection or aortic arch anomalies; coarctation; following aortic angioplasty; periaortic abscess or infection; Pericardial disease (for example): to assess pericardial thickness and detection of metastases; for diagnosing pericardial cysts, pericarditis and constriction; for diagnosing effusion and tamponade; External or internal masses, pathology of lung and pleura (for example): chest wall and mediastinal tumor invasion of the lung and pleura; masses (e.g., lipoma); intracavity tumors and differentiation of tumor from thrombus; assessment of vascular invasion; hilar assessment; pericardial/myocardial invasion; pleural diseases; Pathology involving surrounding structures (for example): to evaluate intrinsic abnormalities of the pulmonary arteries, including central thrombi, aneurysms, stenoses, occlusions, dissection, and extra-vascular disease involving the pulmonary arteries; Assessment of right ventricular cardiomyopathy/dysplasia; Congenital heart disease (for example): ventricular septal defect; atrial septal defect; tetralogy of Fallot; transposition of the great arteries; pulmonary atresia; obstruction to the right ventricular outflow tract; other complex cyanotic heart disease; pulmonary venous anomalies; after surgery for correction of congenital heart disease; Cardiac function, morphology, and structure — ONLY when: it has been determined that echocardiogram is inconclusive or expected to be non-diagnostic; Atrial fibrillation: for assessing left atrial structure and function; for detecting thrombi in the left atrial appendage WHEN echocardiogram is inconclusive; and for identifying pulmonary vein anatomy prior to or after electrophysiology procedures; Diseases of the large veins (for example): acquired and congenital abnormalities of the superior or inferior vena cavae, pulmonary vein system, or portal venous system (e.g., vena caval thrombus; differentiation of tumor thrombus and blood clot of the vena cava; superior vena caval syndrome; superior vena caval invasion or encasement by lung or mediastinal tumors; diagnosis of Budd-Chiari syndrome; and diagnosis of other caval anomalies); Valvular heart disease — ONLY when: it has been determined that echocardiogram and Doppler studies are inconclusive or expected to be non-diagnostic; Coronary artery disease: detection and localization of inducible myocardial perfusion deficits or inducible contractile dysfunction; detection or quantification of the extent of acute or chronic myocardial infarction; differentiation of recent from remote myocardial infarction. NOTE: cardiac MRI, with or without flow reserve, can be used IN PLACE OF, but NOT in addition to, a single photon emission computed tomography (SPECT) — in persons who meet medical necessity criteria for a cardiac SPECT; Demonstration of complications of infarction (for example): formation of an aneurysm; mural thrombus formation; to demonstrate regional wall motion or wall thickening abnormalities of a damaged left ventricle; Cardiomyopathy: to evaluate cardiomyopathies — dilated; restrictive (amyloid); other infiltrative (sarcoid, Fabry, myocardial involvement in systemic myopathies); hypertrophic cardiomyopathy; or due to cardiotoxic therapies; Myocarditis: for further evaluation of suspected acute or chronically active myocarditis; Children with suspected or confirmed pulmonary hypertension / pediatric pulmonary hypertensive vascular disease: as part of the diagnostic evaluation and during follow-up to assess changes in ventricular function and chamber dimensions; Evaluation of anomalous coronary arteries; Cardiac masses: evaluation of cardiac masses WHEN echocardiography is inconclusive. Applies to 5 codes: 75557, 75559, 75561, 75563, 75565.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Requests for cardiac MRI for indications that are not listed above (as medically necessary) are subject to medical review.; Any evidence of duplicative services (e.g., CT scan, radionuclide studies, ultrasound, radioisotope scanning, sonograms, and MRI) is subject to medical review for an evaluation of the medical necessity of the MRI; documentation of a compelling reason / the specific necessary information to be gained from the additional test(s) that the initial test did not provide is required when multiple diagnostic procedures are performed.
Trap
Policy exclusions and limitations: Experimental/investigational: Absolute quantification of myocardial blood flow from cardiac MRI; Experimental/investigational: Blood oxygenation level-dependent (BOLD) cardiac MRI for assessing perfusion in individuals with critical limb ischemia; Experimental/investigational: Cardiac magnetic resonance imaging (cMRI) for early detection of myocardial and aortic diseases in individuals with Turner syndrome; Experimental/investigational: Four-dimensional (4D) flow cardiac MRI for evaluation of ventricular hemodynamics; Experimental/investigational: Intravascular MRI for detecting coronary vulnerable plaques; Experimental/investigational: MRI of the cardiovascular system as a screening test for cardiovascular disease; Experimental/investigational: MRI of the cardiovascular system for acute rejection following heart transplantation; Experimental/investigational: MRI of the cardiovascular system for predicting ventricular tachyarrhythmic events (e.g., sudden cardiac death, resuscitated cardiac arrest, the occurrence of ventricular arrhythmias, and appropriate implantable cardioverter defibrillator therapy); Experimental/investigational: MRI of the cardiovascular system for evaluating patent foramen ovale; Experimental/investigational: MRI of the cardiovascular system for all other indications (except for the ones listed above as medically necessary); Experimental/investigational: Use of ferumoxytol in cardiac magnetic resonance imaging (cMRI), including estimation of fractional myocardial blood volume, evaluation of children with congenital heart disease, and quantitative measure of cardiopathy due to prior treatment with doxorubicin (Adriamycin); Experimental/investigational: Whole heart coronary magnetic resonance angiography for detection of coronary artery disease; Experimental/investigational: Whole-heart coronary MRI for the non-invasive evaluation of the coronary arteries. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0520 — Cardiac MRI

Coverage criteria

  • Thoracic aortic disease (for example): abnormal aortic contour or size on chest X-ray; differentiation of mediastinal mass versus vascular abnormality; to rule out aortic dissection; aneurysm; leaking thoracic aneurysm; exclude aortic source of peripheral embolization; Sinus of Valsalva aneurysm; Marfan's syndrome and aortic annular ectasia; after therapy of aortic dissection or aortic arch anomalies; coarctation; following aortic angioplasty; periaortic abscess or infection
  • Pericardial disease (for example): to assess pericardial thickness and detection of metastases; for diagnosing pericardial cysts, pericarditis and constriction; for diagnosing effusion and tamponade
  • External or internal masses, pathology of lung and pleura (for example): chest wall and mediastinal tumor invasion of the lung and pleura; masses (e.g., lipoma); intracavity tumors and differentiation of tumor from thrombus; assessment of vascular invasion; hilar assessment; pericardial/myocardial invasion; pleural diseases
  • Pathology involving surrounding structures (for example): to evaluate intrinsic abnormalities of the pulmonary arteries, including central thrombi, aneurysms, stenoses, occlusions, dissection, and extra-vascular disease involving the pulmonary arteries
  • Assessment of right ventricular cardiomyopathy/dysplasia
  • Congenital heart disease (for example): ventricular septal defect; atrial septal defect; tetralogy of Fallot; transposition of the great arteries; pulmonary atresia; obstruction to the right ventricular outflow tract; other complex cyanotic heart disease; pulmonary venous anomalies; after surgery for correction of congenital heart disease
  • Cardiac function, morphology, and structure — ONLY when: it has been determined that echocardiogram is inconclusive or expected to be non-diagnostic
  • Atrial fibrillation: for assessing left atrial structure and function; for detecting thrombi in the left atrial appendage WHEN echocardiogram is inconclusive; and for identifying pulmonary vein anatomy prior to or after electrophysiology procedures
  • Diseases of the large veins (for example): acquired and congenital abnormalities of the superior or inferior vena cavae, pulmonary vein system, or portal venous system (e.g., vena caval thrombus; differentiation of tumor thrombus and blood clot of the vena cava; superior vena caval syndrome; superior vena caval invasion or encasement by lung or mediastinal tumors; diagnosis of Budd-Chiari syndrome; and diagnosis of other caval anomalies)
  • Valvular heart disease — ONLY when: it has been determined that echocardiogram and Doppler studies are inconclusive or expected to be non-diagnostic
  • Coronary artery disease: detection and localization of inducible myocardial perfusion deficits or inducible contractile dysfunction; detection or quantification of the extent of acute or chronic myocardial infarction; differentiation of recent from remote myocardial infarction. NOTE: cardiac MRI, with or without flow reserve, can be used IN PLACE OF, but NOT in addition to, a single photon emission computed tomography (SPECT) — in persons who meet medical necessity criteria for a cardiac SPECT
  • Demonstration of complications of infarction (for example): formation of an aneurysm; mural thrombus formation; to demonstrate regional wall motion or wall thickening abnormalities of a damaged left ventricle
  • Cardiomyopathy: to evaluate cardiomyopathies — dilated; restrictive (amyloid); other infiltrative (sarcoid, Fabry, myocardial involvement in systemic myopathies); hypertrophic cardiomyopathy; or due to cardiotoxic therapies
  • Myocarditis: for further evaluation of suspected acute or chronically active myocarditis
  • Children with suspected or confirmed pulmonary hypertension / pediatric pulmonary hypertensive vascular disease: as part of the diagnostic evaluation and during follow-up to assess changes in ventricular function and chamber dimensions
  • Evaluation of anomalous coronary arteries
  • Cardiac masses: evaluation of cardiac masses WHEN echocardiography is inconclusive

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Requests for cardiac MRI for indications that are not listed above (as medically necessary) are subject to medical review.
  • Any evidence of duplicative services (e.g., CT scan, radionuclide studies, ultrasound, radioisotope scanning, sonograms, and MRI) is subject to medical review for an evaluation of the medical necessity of the MRI; documentation of a compelling reason / the specific necessary information to be gained from the additional test(s) that the initial test did not provide is required when multiple diagnostic procedures are performed.

Frequently asked questions

When does Aetna cover Cardiac MRI (CPT 75557), and what gets it denied?
Aetna CPB 0520 covers cardiac MRI / MR angiography of the cardiovascular system as medically necessary only for a defined list of conditions — including thoracic aortic disease, pericardial disease, congenital heart disease, coronary artery disease (as a substitute for, not in addition to, SPECT), cardiomyopathy, myocarditis, anomalous coronary arteries, and diseases of the large veins — with several indications (cardiac function/morphology, valvular disease, atrial-appendage thrombus, cardiac masses) gated on echocardiography/Doppler being inconclusive or expected to be non-diagnostic. Numerous uses (e.g., 4D-flow MRI, whole-heart coronary MRA/MRI, ferumoxytol-enhanced cMRI, screening, transplant-rejection, ventricular-arrhythmia prediction) are experimental/investigational, and any indication not on the list is subject to medical review. Coverage criteria include: Thoracic aortic disease (for example): abnormal aortic contour or size on chest X-ray; differentiation of mediastinal mass versus vascular abnormality; to rule out aortic dissection; aneurysm; leaking thoracic aneurysm; exclude aortic source of peripheral embolization; Sinus of Valsalva aneurysm; Marfan's syndrome and aortic annular ectasia; after therapy of aortic dissection or aortic arch anomalies; coarctation; following aortic angioplasty; periaortic abscess or infection; Pericardial disease (for example): to assess pericardial thickness and detection of metastases; for diagnosing pericardial cysts, pericarditis and constriction; for diagnosing effusion and tamponade; External or internal masses, pathology of lung and pleura (for example): chest wall and mediastinal tumor invasion of the lung and pleura; masses (e.g., lipoma); intracavity tumors and differentiation of tumor from thrombus; assessment of vascular invasion; hilar assessment; pericardial/myocardial invasion; pleural diseases; Pathology involving surrounding structures (for example): to evaluate intrinsic abnormalities of the pulmonary arteries, including central thrombi, aneurysms, stenoses, occlusions, dissection, and extra-vascular disease involving the pulmonary arteries; Assessment of right ventricular cardiomyopathy/dysplasia; Congenital heart disease (for example): ventricular septal defect; atrial septal defect; tetralogy of Fallot; transposition of the great arteries; pulmonary atresia; obstruction to the right ventricular outflow tract; other complex cyanotic heart disease; pulmonary venous anomalies; after surgery for correction of congenital heart disease; Cardiac function, morphology, and structure — ONLY when: it has been determined that echocardiogram is inconclusive or expected to be non-diagnostic; Atrial fibrillation: for assessing left atrial structure and function; for detecting thrombi in the left atrial appendage WHEN echocardiogram is inconclusive; and for identifying pulmonary vein anatomy prior to or after electrophysiology procedures; Diseases of the large veins (for example): acquired and congenital abnormalities of the superior or inferior vena cavae, pulmonary vein system, or portal venous system (e.g., vena caval thrombus; differentiation of tumor thrombus and blood clot of the vena cava; superior vena caval syndrome; superior vena caval invasion or encasement by lung or mediastinal tumors; diagnosis of Budd-Chiari syndrome; and diagnosis of other caval anomalies); Valvular heart disease — ONLY when: it has been determined that echocardiogram and Doppler studies are inconclusive or expected to be non-diagnostic; Coronary artery disease: detection and localization of inducible myocardial perfusion deficits or inducible contractile dysfunction; detection or quantification of the extent of acute or chronic myocardial infarction; differentiation of recent from remote myocardial infarction. NOTE: cardiac MRI, with or without flow reserve, can be used IN PLACE OF, but NOT in addition to, a single photon emission computed tomography (SPECT) — in persons who meet medical necessity criteria for a cardiac SPECT; Demonstration of complications of infarction (for example): formation of an aneurysm; mural thrombus formation; to demonstrate regional wall motion or wall thickening abnormalities of a damaged left ventricle; Cardiomyopathy: to evaluate cardiomyopathies — dilated; restrictive (amyloid); other infiltrative (sarcoid, Fabry, myocardial involvement in systemic myopathies); hypertrophic cardiomyopathy; or due to cardiotoxic therapies; Myocarditis: for further evaluation of suspected acute or chronically active myocarditis; Children with suspected or confirmed pulmonary hypertension / pediatric pulmonary hypertensive vascular disease: as part of the diagnostic evaluation and during follow-up to assess changes in ventricular function and chamber dimensions; Evaluation of anomalous coronary arteries; Cardiac masses: evaluation of cardiac masses WHEN echocardiography is inconclusive. Applies to 5 codes: 75557, 75559, 75561, 75563, 75565. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Requests for cardiac MRI for indications that are not listed above (as medically necessary) are subject to medical review.; Any evidence of duplicative services (e.g., CT scan, radionuclide studies, ultrasound, radioisotope scanning, sonograms, and MRI) is subject to medical review for an evaluation of the medical necessity of the MRI; documentation of a compelling reason / the specific necessary information to be gained from the additional test(s) that the initial test did not provide is required when multiple diagnostic procedures are performed. Policy exclusions and limitations: Experimental/investigational: Absolute quantification of myocardial blood flow from cardiac MRI; Experimental/investigational: Blood oxygenation level-dependent (BOLD) cardiac MRI for assessing perfusion in individuals with critical limb ischemia; Experimental/investigational: Cardiac magnetic resonance imaging (cMRI) for early detection of myocardial and aortic diseases in individuals with Turner syndrome; Experimental/investigational: Four-dimensional (4D) flow cardiac MRI for evaluation of ventricular hemodynamics; Experimental/investigational: Intravascular MRI for detecting coronary vulnerable plaques; Experimental/investigational: MRI of the cardiovascular system as a screening test for cardiovascular disease; Experimental/investigational: MRI of the cardiovascular system for acute rejection following heart transplantation; Experimental/investigational: MRI of the cardiovascular system for predicting ventricular tachyarrhythmic events (e.g., sudden cardiac death, resuscitated cardiac arrest, the occurrence of ventricular arrhythmias, and appropriate implantable cardioverter defibrillator therapy); Experimental/investigational: MRI of the cardiovascular system for evaluating patent foramen ovale; Experimental/investigational: MRI of the cardiovascular system for all other indications (except for the ones listed above as medically necessary); Experimental/investigational: Use of ferumoxytol in cardiac magnetic resonance imaging (cMRI), including estimation of fractional myocardial blood volume, evaluation of children with congenital heart disease, and quantitative measure of cardiopathy due to prior treatment with doxorubicin (Adriamycin); Experimental/investigational: Whole heart coronary magnetic resonance angiography for detection of coronary artery disease; Experimental/investigational: Whole-heart coronary MRI for the non-invasive evaluation of the coronary arteries. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Cardiac MRI?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Requests for cardiac MRI for indications that are not listed above (as medically necessary) are subject to medical review.; Any evidence of duplicative services (e.g., CT scan, radionuclide studies, ultrasound, radioisotope scanning, sonograms, and MRI) is subject to medical review for an evaluation of the medical necessity of the MRI; documentation of a compelling reason / the specific necessary information to be gained from the additional test(s) that the initial test did not provide is required when multiple diagnostic procedures are performed.
What does Aetna exclude for Cardiac MRI?
Policy exclusions and limitations: Experimental/investigational: Absolute quantification of myocardial blood flow from cardiac MRI; Experimental/investigational: Blood oxygenation level-dependent (BOLD) cardiac MRI for assessing perfusion in individuals with critical limb ischemia; Experimental/investigational: Cardiac magnetic resonance imaging (cMRI) for early detection of myocardial and aortic diseases in individuals with Turner syndrome; Experimental/investigational: Four-dimensional (4D) flow cardiac MRI for evaluation of ventricular hemodynamics; Experimental/investigational: Intravascular MRI for detecting coronary vulnerable plaques; Experimental/investigational: MRI of the cardiovascular system as a screening test for cardiovascular disease; Experimental/investigational: MRI of the cardiovascular system for acute rejection following heart transplantation; Experimental/investigational: MRI of the cardiovascular system for predicting ventricular tachyarrhythmic events (e.g., sudden cardiac death, resuscitated cardiac arrest, the occurrence of ventricular arrhythmias, and appropriate implantable cardioverter defibrillator therapy); Experimental/investigational: MRI of the cardiovascular system for evaluating patent foramen ovale; Experimental/investigational: MRI of the cardiovascular system for all other indications (except for the ones listed above as medically necessary); Experimental/investigational: Use of ferumoxytol in cardiac magnetic resonance imaging (cMRI), including estimation of fractional myocardial blood volume, evaluation of children with congenital heart disease, and quantitative measure of cardiopathy due to prior treatment with doxorubicin (Adriamycin); Experimental/investigational: Whole heart coronary magnetic resonance angiography for detection of coronary artery disease; Experimental/investigational: Whole-heart coronary MRI for the non-invasive evaluation of the coronary arteries. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0520 — Cardiac MRI

Related

Need this Aetna approval drafted?

Ask D3 builds the documentation checklist and a ready-to-send request from this policy's criteria — cited, free, no signup.

Ask D3 Free

Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0520 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.