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
Chest Magnetic Resonance Imaging (MRI) generates images of the organs and structures within the chest (thorax) without the use of ionizing radiation. Chest MRI images are affected by motion artifact from respiration, thus is generally not used for evaluation of the lung parenchyma.

Policy 
INDIINDICATIONS FOR CHEST MRI
Chest Wall Pain
Non-traumatic chest wall pain after initial imaging (such as x-ray) has been performed and Chest CT is contraindicated or cannot be performed

• History of known or suspected cancer (no prior x-ray needed) ⁽¹⁾
• Signs and symptoms of infection with concern for chest wall involvement, such as: fever, elevated inflammatory markers, known infection at other sites ⁽¹⁾
• Suspected chest wall injuries (including musculotendinous, costochondral cartilage, sternoclavicular joint, and manubriosternal joint injuries) after non-diagnostic or indeterminate prior imaging (such as x-ray or ultrasound) when imaging will potentially alter management

Brachial Plexopathy (2,3)

• 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) ⁽⁴⁾

• Non-traumatic Brachial Plexopathy (including neurogenic thoracic outlet syndrome) 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.

Vascular Disease (5)

• Superior vena cava (SVC) syndrome ⁽⁶⁾
• Subclavian Steal Syndrome after positive or inconclusive ultrasound when CTA/MRA are contraindicated or cannot be performed ⁽⁷⁾
• Thoracic Outlet Syndrome when CTA/MRA are contraindicated or cannot be performed ⁽⁸⁾
• Pulmonary hypertension when other testing (echocardiogram or right heart catheterization) is suggestive of the diagnosis ^(9,10)

Thoracic Aortic Disease
Acute Aortic Syndromes (AAS)

• For suspected acute aortic syndrome (AAS) such as aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer:
  • Other imaging (such as echocardiogram) is suggestive of AAS OR
  • Individual is either:
    • High risk and one sign/symptom OR non-high risk and two or more signs/symptoms of AAS:
      • High risk conditions:
        • Marfan's syndrome or other connective tissue disease, family history of aortic disease, known aortic valve disease, recent aortic manipulation and/or known thoracic aortic aneurysm
      • Signs  and  symptomsconcerning for AAS:
        • Chest, back or abdominal pain described as abrupt onset, severe in intensity and/or ripping or tearing in quality
        • Pulse deficit or systolic blood pressure differential
        • Focal neurologic deficit with pain
        • New heart murmur with pain
        • Hypotension or shock

• For follow-up of known aortic syndromes, including aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer: frequency for follow up is as clinically indicated ^(11,12)

Congenital Malformations (9,10,13)

• Congenital heart disease with pulmonary hypertension
• Known or suspected pulmonary sequestration
• Congenital non-cardiac non-vascular thoracic malformation on other imaging (such as chest x-ray, echocardiogram, gastrointestinal study or CT) ^(14,15,16)
• Malformations (such as pectus excavatum, pectus carinatum, scoliosis) in patients with cardiorespiratory symptoms for whom treatment is being considered

Evaluation of Tumor

• Mediastinum
  • Thymoma screening in Myasthenia Gravis patients ⁽¹⁷⁾
  • For further evaluation of mediastinal masses on prior imaging
• Chest Wall
  • For further evaluation of chest wall mass after prior indeterminate imaging (18,19) 
• Other Chest Masses
  • For further evaluation of chest mass when prior imaging suggests MRI as the next step rather than CT

Pre-operative/procedural Evaluation

• Pre-operative evaluation for a planned surgery or procedure ⁽¹⁹⁾
• Prior to catheter ablation in patients with atrial fibrillation⁽²⁰⁾

Post-operative/procedural Evaluation

• Post-surgical follow-up when records document medical reason requiring additional imaging
• After catheterablation in patients with atrial fibrillation ⁽²⁰⁾

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.)

Genetic Syndromes and Rare Diseases

• Cystic Fibrosis - chest MRI (or CT) every 2 years and as needed to assess for bronchiectasis
• Multiple Endocrine Neoplasia Syndrome Type 1 (MEN-1⁽²¹⁾) Chest MRI (or CT) annually
• For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance

Combination Studies
Brain/Chest/Abdomen/Pelvis MRI

• Multiple Endocrine Neoplasia Syndrome Type 1 (MEN-1) ⁽²¹⁾
  • Chest/Abdomen/Pelvis annually
  • Brain/Chest/Abdomen/Pelvis every 3 years

Chest MRA (or CTA) and Chest MRI

• When needed for clarification of vascular invasion from tumor

Combination Studies for Malignancy for Initial Staging or Restaging
Unless otherwise specified in this guideline, indication for combination studies for malignancy for initial staging or restaging:

• Concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Abdomen, Brain, Chest, Neck, Pelvis, Cervical Spine, Thoracic Spine or Lumbar Spine.

Background
Magnetic Resonance Imaging (MRI) is a noninvasive imaging technique for detection and evaluation of various disease and conditions in the chest, e.g., congenital anomalies and aneurysms. MRI may be used instead of computed tomography (CT) in patients with allergies to radiographic contrast or with impaired renal function. Also, to decrease radiation exposure, Chest MRI may be used rather than CT when repeated imaging is expected (i.e., surveillance).

Contraindications 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 wight limit/dimensions of MRI machine

References 

1. Stowell J, Walker C, Chung J, Bang T, Carter B et al. ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain. Journal of the American College of Radiology. 2021; 18: S394 - S405. 10.1016/j.jacr.2021.08.004.
2. Belviso I, Palermi S, Sacco A, Romano V, Corrado B et al. Brachial Plexus Injuries in Sport Medicine: Clinical Evaluation, Diagnostic Approaches, Treatment Options, and Rehabilitative Interventions. 2020; 5: 10.3390/jfmk5020022.
3. Rubin D. Brachial and lumbosacral plexopathies: A review. Clinical Neurophysiology Practice. 2020; 5: 173 - 193. https://doi.org/10.1016/j.cnp.2020.07.005.
4. Sinn C. Brachial Plexopathy: Differential Diagnosis and Treatment. PM and R Knowledge Now. 2022; https://now.aapmr.org/brachial-plexopathy-differential-diagnosis-and-treatment-2/.
5. Zurkiya O, Ganguli S, Kalva S, Chung J, Shah L et al. ACR Appropriateness Criteria® Thoracic Outlet Syndrome. J Am Coll Radiol. May 2020; 17: S323-s334. 10.1016/j.jacr.2020.01.029.
6. Friedman T, Quencer K, Kishore S, Winokur R, Madoff D. Malignant Venous Obstruction: Superior Vena Cava Syndrome and Beyond. Semin Intervent Radiol. Dec 2017; 34: 398-408. 10.1055/s-0037- 1608863.
7. Osiro S, Zurada A, Gielecki J, Shoja M, Tubbs R. A review of subclavian steal syndrome with clinical correlation. Med Sci Monit. May 2012; 18: Ra57-63. 10.12659/msm.882721.
8. American College of Radiology. ACR Appropriateness Criteria® Thoracic Outlet Syndrome. American College of Radiology. 2019; Accessed: May 2024. https://acsearch.acr.org/docs/3083061/Narrative/.
9. Beshay S, Sahay S, Humbert M. Evaluation and management of pulmonary arterial hypertension. Respiratory medicine. 2020; 171: 106099.
10. Sharma M, Burns A, Yap T, Prior D. The role of imaging in pulmonary hypertension. Cardiovascular diagnosis and therapy. 2021; 11: 859-880.
11. Barman M. Acute aortic dissection. ESC e-J Cardio Pract. 2014; 12: 02Jul2014. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-12/Acute-aortic-  dissection.
12. American College of Radiology. ACR Appropriateness Criteria® Thoracic Aorta Interventional Planning and Follow-up. 2017.
13. Pascall E, Tulloh R. Pulmonary hypertension in congenital heart disease. Future Cardiol. Jul 2018; 14: 343-353. 10.2217/fca-2017-0065.
14. Bae S, Kang E, Choo K, Lee J, Kim S et al. Aortic Arch Variants and Anomalies: Embryology, Imaging Findings, and Clinical Considerations. J Cardiovasc Imaging. 2022; 30: 231 - 262.
15. Leo I, Sabatino J, Avesani M, Moscatelli S, Bianco F et al. Non-Invasive Imaging Assessment in Patients with Aortic Coarctation: A Contemporary Review. 2024; 13: 10.3390/jcm13010028.
16. Orozco V U H M F. Thoracic Vascular Variants and Anomalies: Imaging Findings, Review of the Embryology, and Clinical Features. Indian Journal of Radiology and Imaging. 2022; 32: 568 - 575. 10.1055/s-0042-1757742.
17. P A T, N M D. The efficiency of chemical-shift MRI for the evaluation of thymoma in patients. La Clinica terapeutica. 2022; 173: 572-578.

18. Ackman J B, Chung J H, Walker C M, Bang T J, Carter B W et al. ACR Appropriateness Criteria® Imaging of Mediastinal Masses. Journal of the American College of Radiology. 2021; 18: S37 - S51. 10.1016/j.jacr.2021.01.007.
19. Nguyen E, Bayanati H, Bilawich A, Tijmes F, Lim R et al. Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Clinical Practice Guidance for Non-Vascular Thoracic MRI. Can Assoc Radiol J. Nov 2021; 72: 831-845. 10.1177/0846537121998961.
20. Kolandaivelu A. Role of Cardiac Imaging (CT/MR) Before and After RF Catheter Ablation in Patients with Atrial Fibrillation. J Atr Fibrillation. Aug-Sep 2012; 5: 523. 10.4022/jafib.523.
21. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Neuroendocrine and Adrenal Tumors Version 1.2023. National Comprehensive Cancer Network®. 2023.

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, 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" 

History From 2024 Forward