Aetna · Clinical coverage policy

Aetna MRI of the Extremities coverage criteria

Aetna CPB 0171 covers MRI of the extremities as medically necessary only for specific indications: knee MRI for tumor, persistent pain/swelling/instability unresponsive to conservative therapy, true locking, suspected osteomyelitis, or unconfirmed osteochondritis dissecans/osteonecrosis; MRI for CLOVES syndrome and foot osteomyelitis; MRI for Morton neuroma pre-op planning after failed non-surgical care; whole-body MRI for Li-Fraumeni malignancy screening; and MRI-lymphangiography for peripheral lymphedema when noninvasive studies are negative. The key gate is that imaging must follow appropriate prior workup (e.g., x-rays, conservative therapy) and most other extremity-MRI uses (e.g., arthritis monitoring, diabetic foot perfusion, DVT, functional/quantitative MRI) are deemed experimental/investigational. The bulletin is silent on precertification/prior authorization.

Policy CPB 0171 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0171

Prior auth

Confirm

Effective

August 18, 1997

This page reflects the coverage criteria captured from Aetna policy CPB 0171 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 MRI of the Extremities (CPT 73721), and what gets it denied?

Path
Aetna CPB 0171 covers MRI of the extremities as medically necessary only for specific indications: knee MRI for tumor, persistent pain/swelling/instability unresponsive to conservative therapy, true locking, suspected osteomyelitis, or unconfirmed osteochondritis dissecans/osteonecrosis; MRI for CLOVES syndrome and foot osteomyelitis; MRI for Morton neuroma pre-op planning after failed non-surgical care; whole-body MRI for Li-Fraumeni malignancy screening; and MRI-lymphangiography for peripheral lymphedema when noninvasive studies are negative. The key gate is that imaging must follow appropriate prior workup (e.g., x-rays, conservative therapy) and most other extremity-MRI uses (e.g., arthritis monitoring, diabetic foot perfusion, DVT, functional/quantitative MRI) are deemed experimental/investigational. The bulletin is silent on precertification/prior authorization. Coverage criteria include: MRI of the knee is medically necessary when ANY of the following criteria is met (items 1-5 below); Knee MRI: Detection, staging, and post-treatment evaluation of tumor of the knee; Knee MRI: Persistent knee pain/swelling and/or instability (giving way) when EITHER (a) NOT associated with an injury AND not responding to at least 3 weeks of conservative therapy; OR (b) secondary to an injury AND not responding to conservative therapy when multi-view x-rays have ruled out a fracture or loose body in the knee and the clinical picture remains uncertain. NOTE: Conservative therapy consists of a combination of rest, ice, compression, elevation, NSAIDs, crutches, and range-of-motion (ROM) exercises; Knee MRI: Persistent true locking of the knee indicative of a torn meniscus or loose body (true locking is more than a momentary locking of the joint with the knee in a flexed position, as compared to the sensation of momentary 'catching' that many individuals experience in extension); Knee MRI: Suspected bone infection (i.e., osteomyelitis); Knee MRI: Suspected osteochondritis dissecans or suspected osteonecrosis, IF the clinical picture, including x-rays, is not confirmatory; MRI for the diagnosis of CLOVES syndrome; MRI for the diagnosis of osteomyelitis in the foot; MRI for Morton neuroma for pre-operative planning WHEN symptomatic neuroma has been identified by plain X-ray AND non-surgical treatments (e.g., metatarsal support, padded shoe insert, and steroid/local anesthetic injections) have failed; Whole-body MRI for screening of malignancy in persons with Li-Fraumeni syndrome; MRI-lymphangiography for the evaluation of peripheral lymphedema WHEN lymphedema is a suspected cause of peripheral edema AND initial noninvasive studies, such as ultrasound, are negative. Applies to 3 codes: 73721, 73722, 73723.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: Knee MRI for all other indications is considered experimental, investigational, or unproven, including ANY of the following circumstances (the items that follow); Knee MRI: Fitting of implants for total knee arthroplasty (experimental/investigational/unproven); Knee MRI: For chronological age estimation (experimental/investigational/unproven); Knee MRI: If arthroscopy or ligament reconstruction is definitely planned and the MRI findings are unlikely to change the planned treatment (experimental/investigational/unproven); Knee MRI: If the clinical picture (i.e., history, physical examination, x-rays, etc.) is diagnostic with a high degree of certainty of a torn meniscus, loose body, or osteochondritis dissecans (experimental/investigational/unproven); Knee MRI: To diagnose or evaluate rheumatoid arthritis or degenerative joint disease (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for assessment of perfusion in diabetic foot ulcer (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis or monitoring of arthritis (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis or prognosis of spinal cord injury and whiplash associated disorder (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis of chronic exertional compartment syndrome (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis of suspected upper extremity deep vein thrombosis (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for evaluation and/or monitoring of disease progression in facioscapulohumeral muscular dystrophy (experimental/investigational/unproven); Functional MRI for evaluation of upper extremity impairment after stroke (experimental/investigational/unproven); Quantitative MRI for evaluation of muscle microtrauma in the lower extremity (experimental/investigational/unproven). Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0171 — MRI of the Extremities

Coverage criteria

  • MRI of the knee is medically necessary when ANY of the following criteria is met (items 1-5 below)
  • Knee MRI: Detection, staging, and post-treatment evaluation of tumor of the knee
  • Knee MRI: Persistent knee pain/swelling and/or instability (giving way) when EITHER (a) NOT associated with an injury AND not responding to at least 3 weeks of conservative therapy; OR (b) secondary to an injury AND not responding to conservative therapy when multi-view x-rays have ruled out a fracture or loose body in the knee and the clinical picture remains uncertain. NOTE: Conservative therapy consists of a combination of rest, ice, compression, elevation, NSAIDs, crutches, and range-of-motion (ROM) exercises
  • Knee MRI: Persistent true locking of the knee indicative of a torn meniscus or loose body (true locking is more than a momentary locking of the joint with the knee in a flexed position, as compared to the sensation of momentary 'catching' that many individuals experience in extension)
  • Knee MRI: Suspected bone infection (i.e., osteomyelitis)
  • Knee MRI: Suspected osteochondritis dissecans or suspected osteonecrosis, IF the clinical picture, including x-rays, is not confirmatory
  • MRI for the diagnosis of CLOVES syndrome
  • MRI for the diagnosis of osteomyelitis in the foot
  • MRI for Morton neuroma for pre-operative planning WHEN symptomatic neuroma has been identified by plain X-ray AND non-surgical treatments (e.g., metatarsal support, padded shoe insert, and steroid/local anesthetic injections) have failed
  • Whole-body MRI for screening of malignancy in persons with Li-Fraumeni syndrome
  • MRI-lymphangiography for the evaluation of peripheral lymphedema WHEN lymphedema is a suspected cause of peripheral edema AND initial noninvasive studies, such as ultrasound, are negative

Covered codes

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

Frequently asked questions

When does Aetna cover MRI of the Extremities (CPT 73721), and what gets it denied?
Aetna CPB 0171 covers MRI of the extremities as medically necessary only for specific indications: knee MRI for tumor, persistent pain/swelling/instability unresponsive to conservative therapy, true locking, suspected osteomyelitis, or unconfirmed osteochondritis dissecans/osteonecrosis; MRI for CLOVES syndrome and foot osteomyelitis; MRI for Morton neuroma pre-op planning after failed non-surgical care; whole-body MRI for Li-Fraumeni malignancy screening; and MRI-lymphangiography for peripheral lymphedema when noninvasive studies are negative. The key gate is that imaging must follow appropriate prior workup (e.g., x-rays, conservative therapy) and most other extremity-MRI uses (e.g., arthritis monitoring, diabetic foot perfusion, DVT, functional/quantitative MRI) are deemed experimental/investigational. The bulletin is silent on precertification/prior authorization. Coverage criteria include: MRI of the knee is medically necessary when ANY of the following criteria is met (items 1-5 below); Knee MRI: Detection, staging, and post-treatment evaluation of tumor of the knee; Knee MRI: Persistent knee pain/swelling and/or instability (giving way) when EITHER (a) NOT associated with an injury AND not responding to at least 3 weeks of conservative therapy; OR (b) secondary to an injury AND not responding to conservative therapy when multi-view x-rays have ruled out a fracture or loose body in the knee and the clinical picture remains uncertain. NOTE: Conservative therapy consists of a combination of rest, ice, compression, elevation, NSAIDs, crutches, and range-of-motion (ROM) exercises; Knee MRI: Persistent true locking of the knee indicative of a torn meniscus or loose body (true locking is more than a momentary locking of the joint with the knee in a flexed position, as compared to the sensation of momentary 'catching' that many individuals experience in extension); Knee MRI: Suspected bone infection (i.e., osteomyelitis); Knee MRI: Suspected osteochondritis dissecans or suspected osteonecrosis, IF the clinical picture, including x-rays, is not confirmatory; MRI for the diagnosis of CLOVES syndrome; MRI for the diagnosis of osteomyelitis in the foot; MRI for Morton neuroma for pre-operative planning WHEN symptomatic neuroma has been identified by plain X-ray AND non-surgical treatments (e.g., metatarsal support, padded shoe insert, and steroid/local anesthetic injections) have failed; Whole-body MRI for screening of malignancy in persons with Li-Fraumeni syndrome; MRI-lymphangiography for the evaluation of peripheral lymphedema WHEN lymphedema is a suspected cause of peripheral edema AND initial noninvasive studies, such as ultrasound, are negative. Applies to 3 codes: 73721, 73722, 73723. 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: Knee MRI for all other indications is considered experimental, investigational, or unproven, including ANY of the following circumstances (the items that follow); Knee MRI: Fitting of implants for total knee arthroplasty (experimental/investigational/unproven); Knee MRI: For chronological age estimation (experimental/investigational/unproven); Knee MRI: If arthroscopy or ligament reconstruction is definitely planned and the MRI findings are unlikely to change the planned treatment (experimental/investigational/unproven); Knee MRI: If the clinical picture (i.e., history, physical examination, x-rays, etc.) is diagnostic with a high degree of certainty of a torn meniscus, loose body, or osteochondritis dissecans (experimental/investigational/unproven); Knee MRI: To diagnose or evaluate rheumatoid arthritis or degenerative joint disease (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for assessment of perfusion in diabetic foot ulcer (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis or monitoring of arthritis (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis or prognosis of spinal cord injury and whiplash associated disorder (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis of chronic exertional compartment syndrome (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis of suspected upper extremity deep vein thrombosis (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for evaluation and/or monitoring of disease progression in facioscapulohumeral muscular dystrophy (experimental/investigational/unproven); Functional MRI for evaluation of upper extremity impairment after stroke (experimental/investigational/unproven); Quantitative MRI for evaluation of muscle microtrauma in the lower extremity (experimental/investigational/unproven). Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for MRI of the Extremities?
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 MRI of the Extremities?
Policy exclusions and limitations: Knee MRI for all other indications is considered experimental, investigational, or unproven, including ANY of the following circumstances (the items that follow); Knee MRI: Fitting of implants for total knee arthroplasty (experimental/investigational/unproven); Knee MRI: For chronological age estimation (experimental/investigational/unproven); Knee MRI: If arthroscopy or ligament reconstruction is definitely planned and the MRI findings are unlikely to change the planned treatment (experimental/investigational/unproven); Knee MRI: If the clinical picture (i.e., history, physical examination, x-rays, etc.) is diagnostic with a high degree of certainty of a torn meniscus, loose body, or osteochondritis dissecans (experimental/investigational/unproven); Knee MRI: To diagnose or evaluate rheumatoid arthritis or degenerative joint disease (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for assessment of perfusion in diabetic foot ulcer (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis or monitoring of arthritis (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis or prognosis of spinal cord injury and whiplash associated disorder (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis of chronic exertional compartment syndrome (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for diagnosis of suspected upper extremity deep vein thrombosis (experimental/investigational/unproven); MRI of the extremities (e.g., hands, knees, feet, etc.) for evaluation and/or monitoring of disease progression in facioscapulohumeral muscular dystrophy (experimental/investigational/unproven); Functional MRI for evaluation of upper extremity impairment after stroke (experimental/investigational/unproven); Quantitative MRI for evaluation of muscle microtrauma in the lower extremity (experimental/investigational/unproven). Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0171 — MRI of the Extremities

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0171 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.