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.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Special Notes

• Plain X-rays must precede MRI evaluation unless otherwise indicated 
• Some indications are for MRI, Computed Tomography (CT), or MR or CT Arthrogram (more than one should NOT be approved at the same time)
• If an MR Arthrogram fits approvable criteria below, approve as MRI

NOTE: Prior completed X-ray showing no clear etiology of joint/extremity pain must precede lower extremity MRI evaluation unless otherwise indicated

Lower extremity pain with no specific joint identified with prior X-ray showing no clear etiology of extremity pain with any ONE of the following:

• Persistent musculotendinous lower extremity pain unresponsive to ACTIVE Conservative Therapy (ACT) which includes physical therapy, chiropractic treatments, and/or physician supervised Home Exercise Program (HEP) of at least four (4) weeks duration within the last 6 months
• With progression or worsening of symptoms during the course of active conservative treatment
• Pediatric patient that is either under the age of 12 years OR cannot comply with the prescribed therapy

In the absence of a positive joint specific orthopedic sign on exam (see list below), advanced imaging is indicated with prior X-ray showing no clear etiology for the joint pain with any ONE of the following:

• Persistent joint pain unresponsive to ACTIVE Conservative Therapy (ACT) which includes physical therapy, chiropractic treatments, and/or physician supervised Home Exercise Program (HEP) of at least four (4) weeks duration within the last 6 months
• With progression or worsening of symptoms during the course of active conservative treatment
• Pediatric patient that is either under the age of 12 years OR cannot comply with the prescribed therapy

NOTE: For Bilateral Hip MRI requests: When the patient meets hip joint MRI criteria for both right and left hip pain (X-ray completed AND persistent pain unresponsive to active conservative therapy) without a positive orthopedic sign, then Pelvis MRI (Evolent_CG_2045) is the preferred study.

Joint Specific Orthopedic Signs

NOTE: With a positive orthopedic sign from the list below, an initial X-ray is always preferred; however, it is NOT required UNLESS otherwise specified in bold below. 

NOTE: The joint specific exam testing list below is intended to be thorough but cannot possibly be all inclusive. Advanced imaging is indicated for any orthopedic exam test that clearly suggests joint instability

Joint specific advanced imaging is indicated for any positive orthopedic sign listed below:

• Physical exam demonstrating a positive result for any ONE of the following tests:

• Positive ankle stress X-rays (a specialized X-ray study that assesses the integrity of the ankle's ligaments and joints)

• Physical exam demonstrating a positive result for any ONE of the following tests:

• Suspected ACL Rupture - acute knee injury with physical exam limited by pain and swelling AFTER initial X-ray completed that does not show a clear etiology with any ONE of the following ⁽¹³⁾ :
  • Extreme mechanism of injury (such as twisting, blunt force)
  • Extreme pain with inability to perform physical examination
  • Instability to stand (bear full weight)
  • Audible pop at time of injury
  • Very swollen joint with inability to perform the physical exam
  • Large knee effusion on recent prior X-ray
• Acute mechanical locking of the knee with inability to move the knee (not due to pain or guarding) ⁽¹⁴⁾
• Suspected patellar dislocation (acute or recurrent) with X-ray findings compatible with a patellar dislocation (such as lipohemarthrosis (a condition where fat/blood build up in joint often after trauma) or osteochondral fracture) ⁽¹⁵⁾

• Physical exam demonstrating a positive result for any ONE of the following tests:

• Suspected Femoroacetabular impingement (FAI) (abnormal bone structure in hip joint causing chronic pain) OR suspected labral tear (specific injury to the cartilage rim (labrum) of the hip socket, labral tear can result from chronic FAI) with any ONE of the following ^(17,18) :
  • Symptoms of hip clicking, locking, catching, giving way or instability with a clinical suspicion of FAI / labral tear
  • X-ray findings suggestive of FAI / labral tear (such as cross over sign, pistol grip deformity, alpha angle over 50 degrees)
  • Determine candidacy for hip preservation surgery for known FAI

For Bilateral Hip MRI requests:

• • When the patient meets the criteria above for a suspected labral tear (with a positive orthopedic sign) then bilateral hip MRIs are the preferred studies (NOT Pelvis MRI) 
  • When Bilateral hip arthrograms are requested and otherwise meet guidelines, bilateral hip MRIs are the preferred studies (NOT Pelvis MRI)

NOTE: When the patient meets hip MRI guidelines for both the right and left hip pain (X-ray completed AND persistent pain unresponsive to active conservative treatment) without a positive orthopedic sign, then Pelvis MRI (Evolent_CG_2045) is the preferred study.

High clinical suspicion of a specific tendon rupture with ALL of the following:

• After X-ray completed
• Mechanism of injury (such as excess muscle/tendon load, direct blow, high speed impact event) and/or physical findings (such as palpable defect in quadriceps, patellar tendon rupture on exam) consistent with possible tendon rupture

• Hip and Femur ⁽²⁰⁾
  • Suspected occult, stress or insufficiency fracture with a negative or indeterminate initial X-ray
    • An immediate MRI is indicated (no follow up X-rays required)
  • Suspicion of a hip fracture in a pregnant patient does NOT require an initial X-ray
• Non-hip lower extremity:
  • Suspected occult, stress, or insufficiency fracture ⁽²¹⁾ with any ONE of the following:
    • X-rays, taken 10-14 days or more after the injury or initial clinical assessment, are negative or indeterminate
    • If the anatomic location of the suspected fracture (such as the navicular bone) puts the patient at high risk for developing a complete fracture with active conservative therapy
  • Suspected Lisfranc injury (complex fracture dislocation of the meta-tarsal joint(s) of the foot) AND prior indeterminate or normal X-ray ⁽²²⁾
    • NOTE: Advanced imaging of the foot (not ankle) is the appropriate study to evaluate a possible Lisfranc injury

• Suspected pathologic fracture on prior X-ray or CT ⁽²¹⁾
• Concern for impending fracture on prior X-ray or CT ⁽²¹⁾
• Suspected nonunion or delayed union as demonstrated by no healing between two sets of X-rays 4 to 8 months or more apart ⁽²³⁾
  • NOTE: CT is the preferred study. MRI approvable if there is contraindication to CT

• Known traumatic fractures on prior imaging with suspected associated ligament or tendon injury

• Clinical suspicion based with completed prior X-ray that is indeterminate or abnormal and any ONE of the following:
  • Suspicious mechanism of injury (such as prior twisting type joint injury, repeated joint microtrauma from running/jumping)
  • Suspicious physical findings (such as focal pain, decreased range of motion, or joint clicking/catching)

• Suspected joint prosthesis complication (such as prosthesis loosening, dysfunction, or pseudotumor formation) with prior X-ray that is indeterminate or abnormal
• Suspected metallosis (increased serum levels of metal ions) with painful metal on metal hip replacement ⁽²⁷⁾ after initial X-rays completed and any ONE of the following:
  • Significantly elevated Cobalt levels (normal level is less than 1.7 micrograms/liter (ppb)) ⁽²⁸⁾
  • Significantly elevated Chromium levels (normal level for patients with metallic implants is less than 2.0 micrograms/liter (ppb)) ⁽²⁸⁾
  • Indeterminate or abnormal joint aspiration (such as findings of metallic debris and absence of infection)

• Vascular malformations of the lower extremity with any ONE of the following ⁽²⁹⁾ :
  • After initial evaluation with ultrasound and advanced imaging results will change management
  • Indeterminate or abnormal prior ultrasound
  • Preoperative planning
  • Follow up after prior surgical treatment and/or embolization

NOTE: MRA of the lower extremity is also indicated with any of the above conditions

• To further characterize a prior abnormal X-ray or CT suggesting osteonecrosis
• Symptomatic and high-risk patients (such as glucocorticosteroid use, renal transplant, glycogen storage disease, alcohol abuse, sickle cell anemia) with normal or indeterminate prior X-ray
• Known osteonecrosis (such as avascular necrosis, Legg-Calve-Perthes Disease) to evaluate the contralateral joint after initial X-rays are abnormal or indeterminate

• To evaluate joint pain or mechanical symptoms suspected to be the results of loose bodies and/or chondromatosis (rare, benign condition where multiple cartilaginous nodules form within the synovial lining of a joint) after prior indeterminate or abnormal imaging (X-ray and /or ultrasound)

• Clinical suspicion of infection of the lower extremity with abnormal or indeterminate prior X-ray or ultrasound
• Negative prior X-ray or ultrasound but with a clinical suspicion of advanced infection based on any ONE of the following:
  • Signs and symptoms of joint or bone infection such as:             
    • Pain and swelling
    • Decreased range of motion
    • Fevers 
  • Laboratory findings consistent with possible bone or joint infection such as:
    • Elevated ESR or CRP
    • Elevated white blood cell count
    • Positive joint aspiration
• Lower extremity ulcer (such as diabetic, pressure, ischemic, or traumatic ulcer) with suspected advanced infection with ALL of the following ^(33,34) :
  • Signs of advanced infection on exam (such as redness, warmth, swelling, exposed bone, bone is encountered when probing the wound, worsening breakdown, worsening smell)
  • No improvement despite prior treatment and bone or deep soft tissue infection is now suspected
• Neuropathic foot with signs of advanced infection (such as friable or discolored granulation tissue, foul odor, purulent or non-purulent discharge, and delayed wound healing) ⁽³⁴⁾

• For suspected inflammatory joint disease (such as rheumatoid arthritis, psoriatic arthritis) with any ONE of the following:
  • Prior indeterminate or abnormal imaging
  • Prior normal imaging but with lab test results (such as RF, CRP, ANA, ESR) that suggest autoimmune disease
• For known inflammatory joint disease (such as rheumatoid arthritis, psoriatic arthritis) with any ONE of the following:
  • Recent indeterminate imaging
  • To assess the response to ongoing active medical therapy where prior imaging and/or labs are currently insufficient or have been insufficient in the past
  • To help determine the need to change ongoing active medical therapy based on new/worsening signs or symptoms (such as joint swelling, tenderness, effusion, erythema, warmth, restricted motion, prolonged morning stiffness)

• For suspected inflammatory myopathy (such as polymyositis, dermatomyositis, immune-mediated necrotizing myopathy, inclusion body myositis) with any ONE of the following:
  • Clinical suspicion based on presenting symptoms (such as symmetric extremity weakness)

• • Clinical suspicion based on lab testing (such as muscle enzyme testing)
  • Clinical suspicion based on prior electromyogram (EMG) results
  • For biopsy planning
• For known inflammatory myopathy (such as polymyositis, dermatomyositis, immune-mediated necrotizing myopathy, inclusion body myositis) with any ONE of the following:
  • Prior indeterminate imaging
  • To assess the response to ongoing active medical therapy where prior imaging and/or labs are or have been insufficient
  • To help determine the need to continue or change ongoing active medical therapy where prior imaging and/or labs are or have been insufficient

• For suspected peripheral nerve entrapment (such as Morton’s neuroma, tarsal tunnel) with any ONE of the following:
  • Abnormal electromyogram or nerve conduction study

• • Abnormal X-ray or ultrasound
  • Failed prior 4-week inactive conservative therapy including at least two of the following (active conservative therapy is NOT required):
    • Activity modification
    • Rest, ice, and/or heat
    • Splinting or orthotics
    • Pharmacotherapy (such as NSAIDs, steroids)

• For known or suspected foreign body of the lower extremity with prior imaging that is indeterminate or abnormal

• Evaluation of painful acquired flatfoot deformity (pes planus) or suspicion of congenital flatfoot deformity (such as tarsal coalition (abnormal fusion of two or more bones in the midfoot or hindfoot)) with ALL of the following:
  • After prior X-ray completed with no clear etiology for pain
  • Failed prior 4-week trial of inactive conservative therapy including at least two of the following (active conservative therapy is NOT required):
    • Activity modification
    • Rest, ice, and/or heat
    • Splinting or orthotics
    • Pharmacotherapy (such as NSAIDs, steroids)
  • NOTE: Prior X-ray is NOT required for pediatric patients

• Osteoid Osteoma – after prior X-ray is indeterminate or abnormal AND when lower extremity CT (the preferred study) is insufficient or not available ⁽⁴⁴⁾
• Suspected Slipped Capital Femoral Epiphysis (SCFE) with indeterminate or negative frog leg lateral and AP X-rays of the hips with any ONE of the following ⁽⁴⁵⁾ :
  • Drehmann sign (The hip remains externally rotated when flexed to 90 degrees and there is pain or inability to internally rotate the hip)
  • Limited internal rotation of the hip
• Suspected Chronic Recurrent Multifocal Osteomyelitis after completion of initial X-ray imaging and laboratory evaluation (such as CRP, ESR) ^(46,47)
  • NOTE: Whole body bone marrow MRI (See Evolent_CG_2007 for Bone Marrow MRI) is preferred when imaging of multiple joints is requested
• Acute limp in a child 5 or less years old ⁽⁴⁸⁾

• Suspected malignancy with prior imaging that is abnormal or indeterminate

• For initial staging of a primary extremity tumor

• Monitoring of a primary extremity tumor on treatment
• End of treatment evaluation of a primary extremity tumor

• Prior to surgery of a primary extremity tumor

• Follow-up of known primary cancer of extremity
  • Every 3-6 months for 2-3 years, then every 6-12 months until 5 years then annually

• Signs or symptoms or imaging findings suspicious for recurrence
• Suspected metastatic disease with signs/symptoms and after initial imaging with X-ray or ultrasound

When not otherwise specified in the guideline

Preoperative Evaluation:

• Imaging of the area requested is needed to develop a surgical plan

Postoperative Evaluation:

• Trendelenburg sign ⁽⁵¹⁾ (contralateral pelvic drop during a single-leg stance) or other indication of muscle or nerve damage after recent hip surgery
• Known or suspected complication
• A clinical reason is provided how imaging may change management

NOTE: This section applies only within the first few months following surgery

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).

• Gaucher Disease ⁽⁵²⁾ :
  • Prior to treatment or dose change OR
  • For evaluation of bone pain

Rationale
MRI
Magnetic resonance imaging (MRI) shows the soft tissues and bones. With its multiplanar capabilities, high contrast, and high spatial resolution, it is an accurate diagnostic tool for conditions affecting the joint and adjacent structures.

MRI can positively influence clinicians’ diagnoses and management plans for patients with conditions such as primary bone cancer, fractures, abnormalities in ligaments/tendons/cartilage, septic arthritis, and infection/inflammation.

Special Note

• Plain X-rays must precede MRI evaluation unless otherwise indicated 
• Some indications are for MRI, Computed Tomography (CT), or MR or CT Arthrogram (more than one should NOT be approved at the same time)
• If an MR Arthrogram fits approvable criteria below, approve as MRI

Background

Conservative therapy should include a multimodality approach consisting of a combination of active and inactive components. Completion of at least one active modality for 4 weeks in the past 6 months is required:

Active Modalities:

• Physical therapy
• Physician-supervised Home Exercise Program (HEP)
• Chiropractic care

Inactive Modalities:

• Medications (e.g., NSAIDs, steroids, analgesics)
• Injections
• Medical Devices (e.g., TENS unit, bracing)

The following two elements are required for HEP to meet the criteria for completion of a trial of active conservative therapy (ACT): 

• Information is provided on specific exercise prescription/plan AND
• Follow-up with patient regarding completion of HEP over at least a 4-week period OR documented inability to complete HEP due to increased pain with inability to physically perform the prescribed exercises.

NOTE: Patient inconvenience or noncompliance without explanation does not meet the “inability to complete HEP” criterium

• 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

EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis ⁽³⁵⁾

Study Design: This study involved a systematic review and consensus process by an expert group of rheumatologists, radiologists, methodologists, and experienced rheumatology practitioners from 13 countries. They generated 13 key questions on the role of imaging in rheumatoid arthritis (RA) and systematically searched research evidence to develop 10 recommendations

Target Population: Adults (≥ 18 years of age) with a clinical diagnosis of RA

Key Factors:

• Imaging modalities included conventional radiography, ultrasound, MRI, CT, dual-emission x-ray absorptiometry, digital x-ray radiogrammetry, scintigraphy, and positron emission tomography.
• The study identified 6888 references, from which 199 studies were included in the systematic review.
• Recommendations covered the role of imaging in diagnosing RA, detecting inflammation and damage, predicting outcome and response to treatment, monitoring disease activity, progression, and remission.

ACR Appropriateness Criteria Stress (Fatigue-Insufficiency) Fracture Including Sacrum Excluding Other Vertebrae: 2024 Update ⁽²¹⁾

Study Design: This study is an update of the American College of Radiology Appropriateness Criteria for stress fractures, including both fatigue and insufficiency types. It involved a systematic analysis of the medical literature from peer-reviewed journals and expert panel reviews

Target Population: Patients with suspected stress fractures, including athletes, older patients, and patients with predisposing conditions

Key Factors:

• Radiography is the imaging modality of choice for baseline diagnosis.
• MRI is preferred for diagnosing radiographically occult stress fractures.
• Nuclear medicine scintigraphy and CT may also be useful diagnostic tools.
• The study emphasizes the importance of prompt therapeutic measures to prevent progression to complete fractures.

Treatment of Acute Achilles Tendon Rupture ⁽⁵⁾

Study Design: This review article provides a comprehensive review of the literature on acute rupture of the Achilles tendon and discusses appropriate treatment options

Target Population: Patients with acute Achilles tendon rupture, including athletes and elderly individuals

Key Factors:

• The Achilles tendon is the strongest and largest tendon in the body but is also the most commonly ruptured.
• The study discusses the controversy surrounding the optimal treatment of acute Achilles tendon rupture, comparing conservative management with operative treatment.
• Recent studies have demonstrated favorable outcomes of conservative treatment using accelerated functional rehabilitation.
• The article emphasizes the importance of early rehabilitation for both conservative and operative treatments

Shared Findings ^(5,21,35) :

• All three studies highlight the importance of imaging in diagnosing and managing musculoskeletal conditions. Colebatch et al 2013 and Morrison et al 2024 emphasize the role of imaging in diagnosing RA and stress fractures, respectively, while Park et al 2020 discusses the use of imaging in diagnosing Achilles tendon ruptures.
• Early intervention and rehabilitation are crucial for improving patient outcomes. Colebatch et al 2013 and Park et al 2020 both stress the importance of early rehabilitation in managing RA and Achilles tendon ruptures.

Conclusion ^(5,21,35)

In summary, while all three studies emphasize the importance of imaging and early intervention, they differ in their focus on specific conditions and treatment options. Colebatch et al 2013 provides recommendations for imaging in RA, Morrison et al 2024 updates criteria for diagnosing stress fractures, and Park et al 2020 reviews treatment options for Achilles tendon ruptures

References

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, 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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