Aetna MRA and MRV coverage criteria

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.

Coverage criteria

• MRA general appropriateness gate: MRA is considered appropriate when it can replace a more invasive test (e.g., contrast angiography) and reduce risk for members
• MRA Head/Neck (medically necessary for ANY of the following): Follow-up for known arterio-venous malformation (AVM)
• MRA Head/Neck: Follow-up for known non-ruptured intracranial aneurysm (ICA) greater than 3 mm
• MRA Head/Neck: Follow-up of intracranial aneurysm (ICA) after coiling
• MRA Head/Neck: To definitively establish presence of stenoses/abnormalities of the vertebrobasilar system in members with symptoms highly suggestive of vertebrobasilar syndrome (ONE of: binocular vision loss, diplopia, dysarthria, dysphagia, positional vertigo)
• MRA Head/Neck: To evaluate signs/symptoms highly suggestive of leaking or ruptured intracranial aneurysm (ICA) or AVM (ONE of: blood in cerebral spinal fluid, stiff neck, sudden explosive headache)
• MRA Head/Neck: To evaluate pulsatile tinnitus with signs/symptoms suggestive of a vascular lesion
• MRA Head/Neck: To rule out intracranial aneurysm (including aneurysms of the circle of Willis) in members at higher risk (examples include: history of intracranial aneurysm in a first-degree relative or presence of polycystic kidney disease)
• MRA Head/Neck: To evaluate carotid artery aneurysm tumor
• MRA Head/Neck: To evaluate cervicocranial arterial dissection in members with suggestive signs/symptoms (examples include: amaurosis fugax, oculo-sympathetic palsy, focal brain ischemia symptoms, unilateral headache)
• MRA Head/Neck: To evaluate carotid artery injury
• MRA Head/Neck: To evaluate carotid stenotic/occlusive disease in asymptomatic candidates for carotid endarterectomy when Duplex Doppler is abnormal
• MRA Head/Neck: To evaluate carotid stenotic/occlusive disease in symptomatic members (cerebro-vascular disease or transient ischemic attack). As MRA is considered an alternative to angiography for evaluation of the carotids, a subsequent angiography is medically necessary only if there is a significant discrepancy between the findings of Duplex ultrasonography and MRA that would impact surgical planning
• MRA Chest (medically necessary for ANY of the following): Diagnosis, treatment planning, and post-operative follow-up for thoracic aorta conditions (examples include: aneurysm [true or pseudoaneurysm], dissection, stenotic/occlusive vascular disease)
• MRA Chest: Diagnosis, treatment planning, and post-operative surgical shunt evaluation in congenital heart disease or developmental anomalies of thoracic vasculature (examples include: atresia/hypoplasia of pulmonary arteries, coarctation of aorta, double aortic arch, interrupted inferior vena cava, partial anomalous venous connection, persistent left superior vena cava, right-sided aortic arch, total anomalous pulmonary venous connection, truncus arteriosus)
• MRA Chest: To diagnose suspected pulmonary embolism when intravascular iodinated contrast is contraindicated, OR as a substitute for pulmonary angiography when V/Q scan does not provide sufficient information for treatment decisions
• MRA Chest: Pulmonary venous and left atrial evaluation pre- and post-radiofrequency ablation for atrial fibrillation
• MRA Spine: Known cases of spinal cord arterio-venous fistula and arterio-venous malformation
• MRA Abdomen/Pelvis (medically necessary for ANY of the following): To assess main renal arteries for renal artery stenosis in persons with refractory uncontrolled hypertension not due to pheochromocytoma. Refractory hypertension is defined as diastolic blood pressure consistently greater than 100 mm Hg on 3 or more blood pressure medications
• MRA Abdomen/Pelvis: To assess persons with sickle cell disease
• MRA Abdomen/Pelvis: To assess pelvic (examples include: aorto-iliac) arteries for stenoses in members with peripheral vascular disease
• MRA Abdomen/Pelvis: To evaluate endoleaks following endovascular repair of abdominal aortic aneurysm
• MRA Abdomen/Pelvis: To evaluate hepatic vasculature prior to TIPS (transjugular intrahepatic portosystemic shunt)
• MRA Abdomen/Pelvis: To determine the extent of abdominal aortic aneurysm and associated occlusive disease in members undergoing elective repair
• MRA Abdomen/Pelvis: To evaluate the body part from which a free tissue transfer flap is taken for breast reconstruction preoperative planning (e.g., abdomen/pelvis for DIEP flap)
• MRA Abdomen/Pelvis: To evaluate for chronic mesenteric ischemia
• MRA Lower Extremity: As the initial test for diagnosis and surgical planning in peripheral arterial disease of the lower extremity. A subsequent angiography study is only required if the inflow vessel is not identified on the MRA. If conventional catheter angiography is performed first, a subsequent MRA may be indicated if a distal run-off vessel is not identified. Both tests should not be routinely performed
• MRA (allergy/renal insufficiency indication): Members with documented allergy to iodinated contrast material
• MRA (allergy/renal insufficiency indication): Members with accelerating hypertension and/or accelerating renal insufficiency
• Gadofosveset trisodium (Ablavar/Vasovist) is considered an appropriate agent for medically necessary contrast-enhanced MRA of the blood vessels of the abdomen and lower extremities in adults
• MRV (medically necessary for ANY of the following): To evaluate thrombosis or compression by tumor of the cerebral venous sinus in at-risk members (examples include: hyper-coagulable disorders, meningitis, oral contraceptive use, otitis media, sinusitis, malignant process) OR in members with signs/symptoms (examples include: drowsiness and confusion accompanying a headache, focal motor/sensory deficits, papilledema, seizures)
• MRV: To evaluate cerebral venous infarction identified on CT or MRI of the head
• MRV: To evaluate pulsatile tinnitus with signs/symptoms suggestive of a vascular lesion
• MRV: To evaluate venous thrombosis/occlusion in large systemic veins (superior vena cava, subclavian, or other deep chest veins)
• MRV: To evaluate venous thrombosis/occlusion in the portal and/or hepatic venous system (examples include: Budd-Chiari syndrome)
• MRV: Chronic pelvic pain when pelvic congestion syndrome is suspected and ultrasound findings are equivocal

Covered codes

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

• 70544·PA verdict·Rate
• 70545·PA verdict·Rate
• 70546·PA verdict·Rate
• 70547·PA verdict·Rate
• 70548·PA verdict·Rate
• 70549·PA verdict·Rate
• 71555·PA verdict·Rate
• 72198·PA verdict·Rate
• 73725·PA verdict·Rate
• 74185·PA verdict·Rate

Frequently asked questions

When does Aetna cover MRA and MRV (CPT 70544), and what gets it denied?

Aetna CPB 0094 covers Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV) as medically necessary for a defined list of vascular indications across the head/neck, chest, spine, abdomen/pelvis, and lower extremities (e.g., follow-up of known aneurysms/AVMs, carotid stenosis evaluation, thoracic/abdominal aortic aneurysm, renal artery stenosis in refractory hypertension, peripheral arterial disease, and specified cerebral/systemic venous thrombosis for MRV). The key gate is that each study must match a listed covered indication; numerous uses (e.g., screening the general population for aneurysms, renal-donor accessory artery evaluation, whole-heart coronary MRA, specific ferumoxytol-enhanced applications such as combined unenhanced CT plus ferumoxytol-enhanced MRA for vascular mapping in renal impairment, ferumoxytol-enhanced MRA for transplant renal artery stenosis, and ferumoxytol-enhanced MRV for chronic kidney disease, and MRV for DVT) are considered experimental/investigational and not covered. The bulletin is silent on precertification/prior authorization. Coverage criteria include: MRA general appropriateness gate: MRA is considered appropriate when it can replace a more invasive test (e.g., contrast angiography) and reduce risk for members; MRA Head/Neck (medically necessary for ANY of the following): Follow-up for known arterio-venous malformation (AVM); MRA Head/Neck: Follow-up for known non-ruptured intracranial aneurysm (ICA) greater than 3 mm; MRA Head/Neck: Follow-up of intracranial aneurysm (ICA) after coiling; MRA Head/Neck: To definitively establish presence of stenoses/abnormalities of the vertebrobasilar system in members with symptoms highly suggestive of vertebrobasilar syndrome (ONE of: binocular vision loss, diplopia, dysarthria, dysphagia, positional vertigo); MRA Head/Neck: To evaluate signs/symptoms highly suggestive of leaking or ruptured intracranial aneurysm (ICA) or AVM (ONE of: blood in cerebral spinal fluid, stiff neck, sudden explosive headache); MRA Head/Neck: To evaluate pulsatile tinnitus with signs/symptoms suggestive of a vascular lesion; MRA Head/Neck: To rule out intracranial aneurysm (including aneurysms of the circle of Willis) in members at higher risk (examples include: history of intracranial aneurysm in a first-degree relative or presence of polycystic kidney disease); MRA Head/Neck: To evaluate carotid artery aneurysm tumor; MRA Head/Neck: To evaluate cervicocranial arterial dissection in members with suggestive signs/symptoms (examples include: amaurosis fugax, oculo-sympathetic palsy, focal brain ischemia symptoms, unilateral headache); MRA Head/Neck: To evaluate carotid artery injury; MRA Head/Neck: To evaluate carotid stenotic/occlusive disease in asymptomatic candidates for carotid endarterectomy when Duplex Doppler is abnormal; MRA Head/Neck: To evaluate carotid stenotic/occlusive disease in symptomatic members (cerebro-vascular disease or transient ischemic attack). As MRA is considered an alternative to angiography for evaluation of the carotids, a subsequent angiography is medically necessary only if there is a significant discrepancy between the findings of Duplex ultrasonography and MRA that would impact surgical planning; MRA Chest (medically necessary for ANY of the following): Diagnosis, treatment planning, and post-operative follow-up for thoracic aorta conditions (examples include: aneurysm [true or pseudoaneurysm], dissection, stenotic/occlusive vascular disease); MRA Chest: Diagnosis, treatment planning, and post-operative surgical shunt evaluation in congenital heart disease or developmental anomalies of thoracic vasculature (examples include: atresia/hypoplasia of pulmonary arteries, coarctation of aorta, double aortic arch, interrupted inferior vena cava, partial anomalous venous connection, persistent left superior vena cava, right-sided aortic arch, total anomalous pulmonary venous connection, truncus arteriosus); MRA Chest: To diagnose suspected pulmonary embolism when intravascular iodinated contrast is contraindicated, OR as a substitute for pulmonary angiography when V/Q scan does not provide sufficient information for treatment decisions; MRA Chest: Pulmonary venous and left atrial evaluation pre- and post-radiofrequency ablation for atrial fibrillation; MRA Spine: Known cases of spinal cord arterio-venous fistula and arterio-venous malformation; MRA Abdomen/Pelvis (medically necessary for ANY of the following): To assess main renal arteries for renal artery stenosis in persons with refractory uncontrolled hypertension not due to pheochromocytoma. Refractory hypertension is defined as diastolic blood pressure consistently greater than 100 mm Hg on 3 or more blood pressure medications; MRA Abdomen/Pelvis: To assess persons with sickle cell disease; MRA Abdomen/Pelvis: To assess pelvic (examples include: aorto-iliac) arteries for stenoses in members with peripheral vascular disease; MRA Abdomen/Pelvis: To evaluate endoleaks following endovascular repair of abdominal aortic aneurysm; MRA Abdomen/Pelvis: To evaluate hepatic vasculature prior to TIPS (transjugular intrahepatic portosystemic shunt); MRA Abdomen/Pelvis: To determine the extent of abdominal aortic aneurysm and associated occlusive disease in members undergoing elective repair; MRA Abdomen/Pelvis: To evaluate the body part from which a free tissue transfer flap is taken for breast reconstruction preoperative planning (e.g., abdomen/pelvis for DIEP flap); MRA Abdomen/Pelvis: To evaluate for chronic mesenteric ischemia; MRA Lower Extremity: As the initial test for diagnosis and surgical planning in peripheral arterial disease of the lower extremity. A subsequent angiography study is only required if the inflow vessel is not identified on the MRA. If conventional catheter angiography is performed first, a subsequent MRA may be indicated if a distal run-off vessel is not identified. Both tests should not be routinely performed; MRA (allergy/renal insufficiency indication): Members with documented allergy to iodinated contrast material; MRA (allergy/renal insufficiency indication): Members with accelerating hypertension and/or accelerating renal insufficiency; Gadofosveset trisodium (Ablavar/Vasovist) is considered an appropriate agent for medically necessary contrast-enhanced MRA of the blood vessels of the abdomen and lower extremities in adults; MRV (medically necessary for ANY of the following): To evaluate thrombosis or compression by tumor of the cerebral venous sinus in at-risk members (examples include: hyper-coagulable disorders, meningitis, oral contraceptive use, otitis media, sinusitis, malignant process) OR in members with signs/symptoms (examples include: drowsiness and confusion accompanying a headache, focal motor/sensory deficits, papilledema, seizures); MRV: To evaluate cerebral venous infarction identified on CT or MRI of the head; MRV: To evaluate pulsatile tinnitus with signs/symptoms suggestive of a vascular lesion; MRV: To evaluate venous thrombosis/occlusion in large systemic veins (superior vena cava, subclavian, or other deep chest veins); MRV: To evaluate venous thrombosis/occlusion in the portal and/or hepatic venous system (examples include: Budd-Chiari syndrome); MRV: Chronic pelvic pain when pelvic congestion syndrome is suspected and ultrasound findings are equivocal. Applies to 10 codes: 70544, 70545, 70546, 70547, 70548, 70549, 71555, 72198, 73725, 74185. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: The following indications are considered experimental, investigational, or unproven because the effectiveness of these approaches has not been established (not an all-inclusive list): MRA is considered experimental, investigational, or unproven for cardiac MRI for velocity flow mapping; MRA is considered experimental, investigational, or unproven for diagnosing cerebral arteriovenous malformations; MRA is considered experimental, investigational, or unproven for evaluating accessory renal arteries in prospective renal donors (including living kidney donors); MRA is considered experimental, investigational, or unproven for evaluating members with symptoms suggestive of dural, sagittal, or cavernous sinus thrombosis/occlusion; MRA is considered experimental, investigational, or unproven for evaluating microvascular compression associated with trigeminal neuralgia; MRA is considered experimental, investigational, or unproven for evaluating premature ventricular contraction; MRA is considered experimental, investigational, or unproven for evaluating recurrent cystic hygroma of the axilla; MRA is considered experimental, investigational, or unproven for evaluating varices at hepatico-jejunostomy after liver transplantation; MRA is considered experimental, investigational, or unproven for evaluating vasa previa; MRA is considered experimental, investigational, or unproven for management of Chiari malformation type I; MRA is considered experimental, investigational, or unproven for predicting pulmonary hypertension; MRA is considered experimental, investigational, or unproven for ruling out intracranial aneurysm (ICA) in members with vague central nervous system symptoms (dizziness, headache, non-specific sensory loss, vertigo); MRA is considered experimental, investigational, or unproven for screening for renovascular hypertension; MRA is considered experimental, investigational, or unproven for screening of the general population for intracranial aneurysms (ICAs); MRA is considered experimental, investigational, or unproven for surveillance of individuals with brain cancer following radiotherapy; Combined unenhanced CT and ferumoxytol-enhanced MRA for vascular mapping in renal impairment is considered experimental, investigational, or unproven; Ferumoxytol-enhanced MRA for evaluation of transplant renal artery stenosis is considered experimental, investigational, or unproven; Non-contrast whole-heart coronary MRA for evaluating coronary artery calcium and coronary stenosis is considered experimental, investigational, or unproven; Whole heart coronary MRA for detection of coronary artery disease is considered experimental, investigational, or unproven; Ferumoxytol-enhanced MRV is considered experimental, investigational, or unproven for diagnosis of chronic kidney disease, mapping lower-extremity venous networks, and evaluating varicose veins in individuals with diabetes mellitus; MRV for diagnosis of deep vein thrombosis (DVT) in the arms or legs is considered experimental, investigational, or unproven (not established as superior to Duplex ultrasonography); MRV is considered experimental, investigational, or unproven for all other indications, including chronic cerebrospinal venous insufficiency, nutcracker syndrome, and prediction of outcome in tuberculous meningitis; Pelvic MRV for diagnostic evaluation of cryptogenic stroke is considered experimental, investigational, or unproven; Quantitative MRV for measurement of venous flow after cerebral venous sinus stenting is considered experimental, investigational, or unproven; MRA of the spinal canal is considered experimental, investigational, or unproven for all other indications. Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for MRA and MRV?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.

What does Aetna exclude for MRA and MRV?

Policy exclusions and limitations: The following indications are considered experimental, investigational, or unproven because the effectiveness of these approaches has not been established (not an all-inclusive list): MRA is considered experimental, investigational, or unproven for cardiac MRI for velocity flow mapping; MRA is considered experimental, investigational, or unproven for diagnosing cerebral arteriovenous malformations; MRA is considered experimental, investigational, or unproven for evaluating accessory renal arteries in prospective renal donors (including living kidney donors); MRA is considered experimental, investigational, or unproven for evaluating members with symptoms suggestive of dural, sagittal, or cavernous sinus thrombosis/occlusion; MRA is considered experimental, investigational, or unproven for evaluating microvascular compression associated with trigeminal neuralgia; MRA is considered experimental, investigational, or unproven for evaluating premature ventricular contraction; MRA is considered experimental, investigational, or unproven for evaluating recurrent cystic hygroma of the axilla; MRA is considered experimental, investigational, or unproven for evaluating varices at hepatico-jejunostomy after liver transplantation; MRA is considered experimental, investigational, or unproven for evaluating vasa previa; MRA is considered experimental, investigational, or unproven for management of Chiari malformation type I; MRA is considered experimental, investigational, or unproven for predicting pulmonary hypertension; MRA is considered experimental, investigational, or unproven for ruling out intracranial aneurysm (ICA) in members with vague central nervous system symptoms (dizziness, headache, non-specific sensory loss, vertigo); MRA is considered experimental, investigational, or unproven for screening for renovascular hypertension; MRA is considered experimental, investigational, or unproven for screening of the general population for intracranial aneurysms (ICAs); MRA is considered experimental, investigational, or unproven for surveillance of individuals with brain cancer following radiotherapy; Combined unenhanced CT and ferumoxytol-enhanced MRA for vascular mapping in renal impairment is considered experimental, investigational, or unproven; Ferumoxytol-enhanced MRA for evaluation of transplant renal artery stenosis is considered experimental, investigational, or unproven; Non-contrast whole-heart coronary MRA for evaluating coronary artery calcium and coronary stenosis is considered experimental, investigational, or unproven; Whole heart coronary MRA for detection of coronary artery disease is considered experimental, investigational, or unproven; Ferumoxytol-enhanced MRV is considered experimental, investigational, or unproven for diagnosis of chronic kidney disease, mapping lower-extremity venous networks, and evaluating varicose veins in individuals with diabetes mellitus; MRV for diagnosis of deep vein thrombosis (DVT) in the arms or legs is considered experimental, investigational, or unproven (not established as superior to Duplex ultrasonography); MRV is considered experimental, investigational, or unproven for all other indications, including chronic cerebrospinal venous insufficiency, nutcracker syndrome, and prediction of outcome in tuberculous meningitis; Pelvic MRV for diagnostic evaluation of cryptogenic stroke is considered experimental, investigational, or unproven; Quantitative MRV for measurement of venous flow after cerebral venous sinus stenting is considered experimental, investigational, or unproven; MRA of the spinal canal is considered experimental, investigational, or unproven for all other indications. Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT