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.

Policy:
IMPORTANT NOTE: Abdomen/Pelvis Magnetic Resonance Angiography (MRA) with Lower Extremity MRA Runoff Requests: Two authorization requests are required, one Abdomen MRA, CPT code 74185 and one for Lower Extremity MRA, CPT code 73725 (a separate Pelvic MRA request is not required). This will provide imaging of the abdomen, pelvis, and both legs. 

AINDICATIONS FOR PELVIS MR ANGIOGRAPHY/MR VENOGRAPHY (MRA/MRV)
Abdominal Aortic Disease
Abdominal Aortic Aneurysm

• Asymptomatic known or suspected abdominal aortic aneurysms when prior ultrasound is inconclusive or insufficient AND when CT/CTA is contraindicated or cannot be performed
• Symptomatic known or suspected Abdominal Aortic Aneurysm(1,2)
  • Symptoms may include:
    • Abrupt onset of severe sharp or stabbing pain in the chest, back or abdomen
    • Acute abdominal or back pain with a pulsatile or epigastric mass
    • Acute abdominal or back pain and at high risk for aortic aneurysm and/or aortic syndrome (risk factors include hypertension, atherosclerosis, prior cardiac or aortic surgery, underlying aneurysm, connective tissue disorder (e.g., Marfan syndrome, vascular form of Ehlers-Danlos syndrome, Loeys-Dietz syndrome), and bicuspid aortic valve)(3)

Aortic Syndromes
For initial diagnosis of suspected and follow-up of known aortic syndromes, including aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer

• Frequency for follow up is as clinically indicated

Postoperative Follow-up of Aortic Repair
Follow-up for post-endovascular repair (EVAR) or open repair of AAA(1) or abdominal extent of iliac artery aneurysms at the following intervals:

• Routine, baseline post-EVAR study when CT/CTA is contraindicated or cannot be performed:
  • Within one month of procedure
  • Continued follow up imaging at the following intervals:
    • If no endoleak or sac enlargement is seen:
      • Annually monitor with ultrasound
        • When US is abnormal or insufficient CT/MR can be using to monitor annually
      • Every 5 years monitor with CT/MR
    • If type II endoleak or sac enlargement is seen at any point in time (US not needed):
      • Monitor every 6 months x 2 years, then annually (does not require US)
• Routine follow up after open repair of AAA when CT/CTA is contraindicated or cannot be performed:(2)
  • Within 1 year postoperatively then
  • Annually monitor with ultrasound
    • When US is abnormal or insufficient CT/MR can be used to monitor annually
  • Every 5 years monitor with CT/MR
• If symptomatic or imaging shows increasing, or new findings related to stent graft – more frequent imaging may be needed as clinically indicated
• Suspected complication such as: new-onset lower extremity claudication, ischemia, or reduction in ABI after aneurysm repair

Ischemia or Hemorrhage

• To determine the vascular source of retroperitoneal hematoma or hemorrhage when CT is insufficient to determine the source and CTA is contraindicated or cannot be performed; (CT rather than MRA/CTA is the modality of choice for diagnosing hemorrhage)(4)
• Evaluation of known or suspected mesenteric ischemia/ischemic colitis when CTA is contraindicated or cannot be performed(5)

Other Vascular Abnormalities

• Initial evaluation of inconclusive vascular findings on prior imaging
• For evaluation or monitoring of pelvic vascular disease when ultrasound is inconclusive(3,6,7,8)
  • Includes abnormalities such as aneurysm, dissection, arteriovenous malformations (AVM), vascular fistula, intramural hematoma, compression syndromes and vasculitis involving any of the following: inferior vena cava, iliac arteries/veins and/or other pelvic blood vessels
• For assessment in patients with spontaneous coronary artery dissection (SCAD), can be done at time of coronary angiography(9)
• Suspected complications of known aneurysm as evidenced by clinical findings such as new onset of pelvic pain

Venous Disease

• Evaluation of suspected pelvic vascular disease or pelvic congestive syndrome when findings on ultrasound are indeterminate(10,11)
• Unexplained lower extremity edema (typically unilateral or asymmetric) with negative or inconclusive Abdomen and/or Pelvis CT(12)
• Venous thrombosis (including inferior vena cava thrombosis) if previous studies (such as ultrasound) have not resulted in a clear diagnosis(13,14)
• Known/suspected May-Thurner Syndrome (iliac vein compression syndrome) when CTV is contraindicated or cannot be performed(15,16)
• For pregnant women with suspected deep venous thrombosis (DVT) (including suspected extension to the iliac vein) after compression ultrasound(17)

Evaluation of Tumor

• When needed for clarification of vascular invasion from tumor(18)
• For imaging of the deep inferior epigastric arteries prior to breast reconstructive surgery

Pre-Operative Evaluation and/or Pre-Procedural Evaluation(19,20,21)

• Evaluation prior to interventional vascular for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia
• Evaluation prior to endovascular aneurysm repair (EVAR)
• Evaluation prior to Transcatheter Aortic Valve Replacement (TAVR) CTA is contraindicated or cannot be performed(22)
• For imaging of the deep inferior epigastric arteries prior to breast reconstructivesurgery
• Evaluation of vascular anatomy prior to solid organ transplantation
• Prior to uterine artery embolization for fibroids(23)
• For evaluation of erectile dysfunction when a vascular cause is confirmed by doppler ultrasound, revascularization is planned and there is a contraindication to selective

internal pudendal angiography (SIPA)(24)
Post-Operative Evaluation and/or Post-Procedural Evaluation

• Follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.
• Endovascular/interventional vascular procedures for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia
• Post-operative complications (e.g., pseudoaneurysms related to surgical bypass grafts, vascular stents, and stent-grafts in the pelvis)
• Post-operative complications of renal transplant allograft(25)

Genetic Syndrome and Rare Diseases

• For patients with fibromuscular dysplasia (FMD):(26,27)
  • One-time vascular study from brain to pelvis
• Vascular Ehlers-Danlos syndrome:(28,29)
  • At diagnosis and then every 18 months
  • More frequently if abnormalities are found
• Marfan syndrome:(30)
  • At diagnosis and then every 3 years
  • More frequently (annually) if EITHER: history of dissection, dilation of aorta beyond aortic root OR aortic root/ascending aorta are not adequately visualized on TTE (i.e., advanced imaging is needed to monitor the thoracic aorta)(2,31)
• Loeys-Dietz:
  • At diagnosis and then every two years
  • More frequently if abnormalities are found(32)
• Williams Syndrome:(33)
  • When there is concern for vascular disease (including renal artery stenosis) based on abnormal exam or imaging findings (such as diminished pulses, bruits or signs of diffuse thoracic aortic stenosis)
• Neurofibromatosis Type 1 (NF-1):(34)
  • Development of hypertension (including concern for renal artery stenosis)
• Takayasu's Arteritis:(35)
  • For evaluation at diagnosis then as clinically indicated
• 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
Abdomen/Pelvis MRA

• As a dedicated CPT code does not exist for Abdomen and Pelvis MRA, when a disease process is reasonably expected to involve both the abdomen and pelvis AND the guideline criteria have been met, two separate authorizations are required: Abdomen MRA (CPT code 74185) and Pelvis MRA (CPT 72198)

Brain/Neck/Chest/Abdomen/Pelvis MRA

• For patients with fibromuscular dysplasia (FMD), a one-time vascular study from brain to pelvis(26,27)
• Vascular Ehlers-Danlos syndrome: At diagnosis and then every 18 months; more frequently if abnormalities are found(28,29)
• Loeys-Dietz: at diagnosis and then every two years, more frequently if abnormalities are found(32)
• For assessment in patients with spontaneous coronary artery dissection (SCAD), can be done at time of coronary angiography(9)

Chest/Abdomen/Pelvis MRA

• Evaluation prior to endovascular aneurysm repair (EVAR) when thoracic involvement is present
• Evaluation prior to Transcatheter Aortic Valve Replacement (TAVR) when CTA is contraindicated or cannot be performed(22)
• Marfan syndrome:(30)
  • At diagnosis and every 3 years
  • More frequently (annually) if EITHER: history of dissection, dilation of aorta beyond aortic root OR aortic root/ascending aorta are not adequately visualized on TTE (i.e., advanced imaging is needed to monitor the thoracic aorta)(2,31)
• Williams Syndrome(33)
  • When there is concern for vascular disease (including renal artery stenosis) based on abnormal exam or imaging findings (such as diminished pulses, bruits or signs of diffuse thoracic aortic stenosis)
• Acute aortic dissection(36)
• Significant post-traumatic or post-procedural vascular complications reasonably expected to involve the chest, abdomen and pelvis 

Neck/Chest/Abdomen/Pelvis MRA

• Takayasu's Arteritis: For evaluation at diagnosis then as clinically indicated(35)

Pelvis MRA and Pelvis MRI (or CT)

• When needed for clarification of vascular invasion from tumor (including suspected renal vein thrombosis)(18)
• Prior to uterine artery embolization for fibroids(23)

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)

Rationale
Purpose
Magnetic resonance angiography (MRA) and (MRV) generates images of the blood vesselsthat can be evaluated for evidence of stenosis, occlusion, or aneurysms without use ofionizing radiation. It is used to evaluate the blood vessels of the pelvis.

Special Note
When the criteria for imaging of peripheral vascular disease are met (see relevant guidelines), two separate authorizations are required: Abdomen MRA (CPT 74185) and one
Lower Extremity MRA (CPT 73725). This will provide imaging of the abdomen, pelvis and both legs. A separate Pelvis MRA authorization is NOT required. Only one Lower Extremity MRA is required (not two).

Abdominal Aneurysms and General Guidelines for Follow-Up
The normal diameter of the suprarenal abdominal aorta is 3.0 cm and that of the infrarenal is2.0 cm. Aneurysmal dilation of the infrarenal aorta is defined as diameter ≥ 3.0 cm or dilatation of the aorta ≥ 1.5x the normal diameter.

Iliac Aneurysm Ultrasound Screening Intervals

• Aneurysm size 2.0-2.9 cm, every 3 years
• Aneurysm size 3.0-3.4 cm, annually
• Aneurysm size > 3.5 cm, every 6 months(3)

MRI/CT and Acute Hemorrhage
MRI is not indicated and MRA/MRV (MR Angiography/Venography) is rarely indicated for evaluation of intraperitoneal or retroperitoneal hemorrhage, particularly in the acute setting. CT is the study of choice due to its availability, speed of the study, and less susceptibility to artifact from patient motion. Advances in technology have allowed conventional CT to detect hematomas and the source of acute vascular extravasation. In special cases, finer vascular detail to assess the specific source vessel responsible for hemorrhage may require the use of CTA (e.g., for the diagnosis of lower gastrointestinal bleeding).(37)

MRA/MRV is often utilized in non-acute situations to assess vascular structure involved in atherosclerotic disease with associated complications, vasculitis, venous thrombosis,
vascular congestion, or tumor invasion. Although some may be associated with hemorrhage, it is usually not the primary reason why MRI/MRA/MRV is selected for the evaluation. A special condition where MRI may be superior to CT for evaluating hemorrhage is to detect an underlying neoplasm as the cause of bleeding.(4)

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 noncompatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine

References 

1. Chaikof E, Dalman R, Eskandari M, Jackson B, Lee W et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018; 67: 2-77.e2. 10.1016/j.jvs.2017.10.044.
2. Isselbacher E, Preventza O, Hamilton Black J, Augoustides J, Beck A et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022; 146: e334-e482. 10.1161/CIR.0000000000001106.
3. Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M et al. European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019; 57: 8-93. 10.1016/j.ejvs.2018.09.020.
4. Verma N, Steigner M, Aghayev A, Azene E, Chong S et al. ACR Appropriateness Criteria® Suspected Retroperitoneal Bleed. Journal of the American College of Radiology. 2021; 18: S482 - S487. https://doi.org/10.1016/j.jacr.2021.09.003.
5. Lam A, Kim Y, Fidelman N, Higgins M, Cash B et al. ACR Appropriateness Criteria® Radiologic Management of Mesenteric Ischemia: 2022. Journal of the American College of Radiology : JACR. 2022; 19: S433-S444. 10.1016/j.jacr.2022.09.006.
6. Juntermanns B, Bernheim J, Karaindros K, Walensi M, Hoffmann J N. Visceral artery aneurysms. Gefasschirurgie : Zeitschrift fur vaskulare und endovaskulare Chirurgie : Organ. 2018; 23: 19-22. 10.1007/s00772-018-0384-x.
7. Knuttinen M, Xie K, Jani A, Palumbo A, Carrillo T. Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeutic issues. AJR Am J Roentgenol. 2015; 204: 448-58. 10.2214/ajr.14.12709.
8. Makazu M, Koizumi K, Masuda S, Jinushi R, Shionoya K. Spontaneous retroperitoneal hematoma with duodenal obstruction with diagnostic use of endoscopic ultrasound: A case series and literature review. Clinical journal of gastroenterology. 2023; 16: 377-386. 10.1007/s12328-023-01780-3.
9. Teruzzi G, Santagostino Baldi G, Gili S, Guarnieri G, Montorsi P. Spontaneous Coronary Artery Dissections: A Systematic Review. Journal of clinical medicine. 2021; 10: 10.3390/jcm10245925.
10. Kashef E, Evans E, Patel N, Agrawal D, Hemingway A. Pelvic venous congestion syndrome: female venous congestive syndromes and endovascular treatment options. CVIR endovascular. 2023; 6: 25. 10.1186/s42155-023-00365-y.
11. Rezaei-Kalantari K, Fahrni G, Rotzinger D, Qanadli S. Insights into pelvic venous disorders. Frontiers in Cardiovascular Medicine. 2023; 10: 10.3389/fcvm.2023.1102063.
12. Gasparis A, Kim P, Dean S, Khilnani N, Labropoulos N. Diagnostic approach to lower limb edema. Phlebology. 2020; 35: 650 - 655. 10.1177/0268355520938283.
13. Aw-Zoretic J, Collins J. Considerations for Imaging the Inferior Vena Cava (IVC) with/without IVC Filters. Semin Intervent Radiol. 2016; 33: 109-21. 10.1055/s-0036-1583207.
14. Hanley M, Steigner M, Ahmed O, Azene E, Bennett S et al. ACR Appropriateness Criteria (®) Suspected Lower Extremity Deep Vein Thrombosis. Journal of the American College of Radiology : JACR. 2018; 15: S413-S417. 10.1016/j.jacr.2018.09.028.
15. Knuttinen M, Naidu S, Oklu R, Kriegshauser S, Eversman W et al. May-Thurner: diagnosis and endovascular management. Cardiovascular diagnosis and therapy. 2017; 7: true. 10.21037/cdt.2017.10.14.
16. Shammas N, Jones-Miller S, Kovach T, Radaideh Q, Patel N et al. Predicting Significant Iliac Vein Compression Using a Probability Scoring System Derived from Minimal Luminal Area on Computed Tomography Angiography in Patients 65 Years of Age or Younger. J Invasive Cardiol. 2021; 33: E16-E18.
17. Bates S, Rajasekhar A, Middeldorp S, McLintock C, Rodger M et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood advances. 2018; 2: 3317-3359.10.1182/bloodadvances.2018024802.
18. Čertík B, Třeška V, Moláček J, Šulc R. How to proceed in the case of a tumour thrombus in the inferior vena cava with renal cell carcinoma. Cor et Vasa. 2015; 57: e95-e100. https://doi.org/10.1016/j.crvasa.2015.02.015.
19. Francois C, Skulborstad E, Majdalany B, Chandra A, Collins J et al. ACR Appropriateness Criteria(®) Abdominal Aortic Aneurysm: Interventional Planning and Follow-Up. Journal of the American College of Radiology : JACR. 2018; 15: S2-S12. 10.1016/j.jacr.2018.03.008.
20. Leipsic J, Blanke P, Hanley M, Batlle J, Bolen M et al. ACR Appropriateness Criteria(®) Imaging for Transcatheter Aortic Valve Replacement. Journal of the American College of Radiology : JACR. 2017; 14: S449-S455. 10.1016/j.jacr.2017.08.046.
21. Singh N, Aghayev A, Ahmad S, Azene E, Ferencik M et al. ACR Appropriateness Criteria® Imaging of Deep Inferior Epigastric Arteries for Surgical Planning (Breast Reconstruction Surgery): 2022 Update. Journal of the American College of Radiology : JACR. 2022; 19: S357-S363.10.1016/j.jacr.2022.09.004.
22. Hedgire S, Saboo S, Galizia M, Aghayev A, Bolen M et al. ACR Appropriateness Criteria® Preprocedural Planning for Transcatheter Aortic Valve Replacement: 2023 Update. Journal of the American College of Radiology. 2023; 20: S501 - S512. 10.1016/j.jacr.2023.08.009.
23. Maciel C, Tang Y, Sahdev A, Madureira A, Vilares Morgado P. Preprocedural MRI and MRA in planning fibroid embolization. Diagn Interv Radiol. 2017; 23: 163-171. 10.5152/dir.2016.16623.
24. Burnett A, Nehra A, Breau R, Culkin D, Faraday M et al. Erectile Dysfunction: AUA Guideline. The Journal of urology. 2018; 200: 633-641. 10.1016/j.juro.2018.05.004.
25. Serhal A, Aouad P, Serhal M, Pathrose A, Lombardi P et al. Evaluation of Renal Allograft Vasculature Using Non-contrast 3D Inversion. Exploratory research and hypothesis in medicine. 2021; 6: 90-98. 10.14218/ERHM.2021.00011.
26. Gornik H, Persu A, Adlam D, Aparicio L, Azizi M et al. First International Consensus on the diagnosis and management of fibromuscular dysplasia. Vascular Medicine. 2019; 24: 164 - 189. 10.1177/1358863X18821816.
27. Kesav P, Manesh Raj D, John S. Cerebrovascular Fibromuscular Dysplasia - A Practical Review. Vascular health and risk management. 2023; 19: 543-556. 10.2147/VHRM.S388257.
28. Bowen J, Hernandez M, Johnson D, Green C, Kammin T et al. Diagnosis and management of vascular Ehlers-Danlos syndrome: Experience of the UK national diagnostic service, Sheffield. European Journal of Human Genetics. 2023; 31: 749 - 760. 10.1038/s41431-023-01343-7.
29. Byers P. Vascular Ehlers-Danlos Syndrome. [Updated 2019 Feb 21]. GeneReviews® [Internet]. 2019;
30. Dietz H. FBN1-Related Marfan Syndrome. [Updated 2022 Feb 17]. GeneReviews® [Internet]. 2022; Accessed May 2024:
31. Weinrich J, Lenz A, Schön G, Behzadi C, Molwitz L et al. Magnetic resonance angiography derived predictors of progressive dilatation and. PloS one. 2022; 17: e0262826.10.1371/journal.pone.0262826.
32. Loeys B, Dietz H. Loeys-Dietz Syndrome. [Updated 2018 March 1]. GeneReviews® [Internet]. 2018;
33. Morris C. Williams Syndrome. [Updated 2023 Apr 13]. GeneReviews® [Internet]. 2023;
34. Friedman J. Neurofibromatosis 1. [Updated 2022 Apr 21]. GeneReviews® [Internet]. 2022;
35. Maz M, Chung S, Abril A, Langford C, Gorelik M et al. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis. Arthritis & rheumatology (Hoboken, N.J.). 2021; 73: 1349-1365.
36. Kicska G, Hurwitz Koweek L, Ghoshhajra B, Beache G, Brown R et al. ACR Appropriateness Criteria® Suspected Acute Aortic Syndrome. Journal of the American College of Radiology. 2021; 18: S474 - S481. 10.1016/j.jacr.2021.09.004.
37. Clerc D, Grass F, Schäfer M, Denys A, Demartines N. Lower gastrointestinal bleeding-Computed Tomographic Angiography, Colonoscopy or both? World J Emerg Surg. 2017; 12: 1. 10.1186/s13017-016-0112-3.

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" 

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