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.

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 and Injuries

• Non-traumatic chest wall pain with normal chest x-ray or rib x-ray with any ONE of the following and CT is contraindicated or cannot be performed ⁽¹⁾
  • Signs and symptoms of infection, such as fever, elevated inflammatory markers, known infection at other sites
  • History of chest radiation or chest surgery
• Suspected chest wall injuries (such as 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

• Traumatic Brachial Plexopathy: If mechanism of injury is highly suspicious for brachial plexopathy (such as birth trauma, mid-clavicular fracture, shoulder dislocation, contact injury to the neck (burner or stinger syndrome) or penetrating injury) ⁽⁶⁾
• 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 needed to appropriately image the brachial plexus.

• Superior vena cava (SVC) syndrome when CTA/MRA are contraindicated or cannot be performed ⁽⁷⁾
• Subclavian Steal Syndrome after positive or inconclusive ultrasound when CTA/MRA are contraindicated or cannot be performed ⁽⁸⁾
• Neurogenic or venous thoracic outlet syndrome ⁽⁹⁾
• Arterial thoracic outlet syndrome when CTA and MRA are contraindicated or cannot be performed ⁽⁹⁾
• Pulmonary hypertension when other testing (echocardiogram or right heart catheterization) is suggestive of the diagnosis ^(10,11)

• For suspected acute aortic syndrome (AAS) (such as aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer) with any ONE of the following:
  • Prior imaging (such as echocardiogram) is suggestive of AAS
  • High risk patient for AAS and one sign/symptom concerning for AAS:
    • High risk conditions for AAS:
      • 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 symptoms concerning 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
  • Non-high-risk patient and two or more signs/symptoms concerning for AAS (see above)
• For follow-up of known aortic syndromes, including aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer: frequency for follow up is as clinically indicated
• Suspected vascular cause of dysphagia (from vascular compression of the esophagus) or expiratory wheezing (from vascular compression of the trachea/bronchus) with prior imaging that is indeterminate or abnormal.

• Follow-up thoracic endovascular aortic repair (TEVAR) at the following intervals ^(12,14) :
  • Baseline study at 1 month post-EVAR
  • Annually thereafter if stable
    • More frequent imaging (as clinically indicated) may be needed if there are complications or abnormal findings on surveillance imaging
  • After 5 post-operative years without complications, continuing follow-up every 5 years should be considered
• Follow up after thoracic aorta open repair at the following intervals:
  • At one year post-repair
  • Every 5 years thereafter
• If abnormal findings are seen on any surveillance imaging study, imaging is then done annually

• Congenital heart disease with pulmonary hypertension ⁽¹⁵⁾
• Known or suspected pulmonary sequestration ⁽¹⁶⁾
• Congenital non-cardiac non-vascular thoracic malformation on other imaging (such as chest x-ray, echocardiogram, gastrointestinal study or CT) ^(16,17)
• Chest wall malformations (such as pectus excavatum, pectus carinatum, scoliosis) in patients with cardiorespiratory symptoms for whom treatment is being considered ⁽¹⁸⁾

• Mediastinum
  • Evaluation for suspected thymoma in Myasthenia Gravis patients ⁽¹⁹⁾
  • For further evaluation of mediastinal masses on prior imaging ⁽²⁰⁾
• Chest Wall ^(21,22)
  • For further evaluation of chest wall mass after prior indeterminate imaging

• Other Chest Masses ⁽²²⁾
  • For further evaluation of chest mass when prior imaging suggests MRI as the next step rather than CT

When not otherwise specified in the guideline:

Preoperative Evaluation:

• Prior to catheter ablation in patients with atrial fibrillation ⁽²³⁾
• Imaging of the area is needed to develop a surgical plan

Postoperative Evaluation

• After catheter ablation in patients with atrial fibrillation if complications are suspected  ⁽²³⁾
• Known or suspected complications
• 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).

• ADPKD (Autosomal Dominant Polycystic Kidney Disease) AND family history of thoracic aortic dissection: every 2 years (including at diagnosis) ⁽²⁴⁾

NOTE: either cardiac MRI or Chest MRI is indicated for surveillance, not both

• BAP1-TPDS (BAP-1 tumor predisposition syndrome): with clinical concerns for malignant mesothelioma ⁽²⁵⁾
• Cystic Fibrosis - chest MRI (or CT) every 2 years and as needed to assess for bronchiectasis ⁽²⁶⁾
• Multiple Endocrine Neoplasia Syndrome Type 1 (MEN-1): annually starting at age 8  ^(27,28)
• For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance

NOTE: When medical necessity is met for an individual study AND conscious sedation is required (such as for young pediatric patients or patients with significant developmental delay), the entire combination is indicated)

• Multiple Endocrine Neoplasia Syndrome Type 1 (MEN-1) ^(27,28) :
  • Annually starting at age 8
  • NOTE: Every 3 years include Brain MRI

NOTE: When medical necessity is met for an individual study AND conscious sedation is required (such as for young pediatric patients or patients with significant developmental delay), the entire combination is indicated)

• When needed for clarification of vascular involvement from tumor

• Advanced imaging for Granulomatosis with Polyangiitis (GPA) (Formally Wegener’s Granulomatosis) is indicated with any ONE of the following ⁽²⁹⁾ :
  • Suspected GPA based on clinical findings (such as biopsy results, lab testing including antineutrophil cytoplasmic antibodies (ANCA))
  • Known GPA when imaging results of a specific anatomic area is needed to guide systemic therapy decisions

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

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

ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain ⁽¹⁾

Study Design: This document is an update of the ACR Appropriateness Criteria for Nontraumatic Chest Wall Pain, developed by a multidisciplinary expert panel. It includes an extensive analysis of current medical literature from peer-reviewed journals.

Target Population: Patients presenting with nontraumatic chest wall pain, including those with no history of malignancy, known or suspected malignancy, suspected infectious or inflammatory conditions, and history of prior chest intervention.

Key Factors: Recommendations for initial and secondary imaging strategies, including radiography, CT, MRI, ultrasound, bone scan, and PET/CT. Specific guidelines for different clinical scenarios such as chest wall pain with no history of malignancy, known or suspected malignancy, and suspected infectious or inflammatory conditions. Evaluation of the diagnostic performance of various imaging modalities in detecting chest wall pain.

ACR Appropriateness Criteria® Plexopathy: 2021 Update ⁽⁴⁾

Study Design: This document is an update of the ACR Appropriateness Criteria for Plexopathy, developed by a multidisciplinary expert panel. It includes an extensive analysis of current medical literature from peer-reviewed journals.

Target Population: Patients presenting with brachial or lumbosacral plexopathy due to various pathologies such as trauma, nerve entrapment, neoplasm, inflammation, infection, autoimmune disease, hereditary disease, and idiopathic etiologies.

Key Factors: Recommendations for initial imaging strategies, including MRI, CT, ultrasound, and PET/CT. Specific guidelines for different clinical scenarios such as nontraumatic plexopathy, traumatic plexopathy, and plexopathy in the context of known malignancy or post-treatment syndrome. Evaluation of the diagnostic performance of various imaging modalities in detecting plexopathy.

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 ⁽¹²⁾

Study Design: This document is a clinical practice guideline developed by the American Heart Association (AHA) and the American College of Cardiology (ACC) Joint Committee on Clinical Practice Guidelines. It is based on a comprehensive literature review conducted from January 2021 to April 2021, including studies, reviews, and other evidence published in English.

Target Population: The guideline is intended for clinicians managing patients with aortic disease, including asymptomatic, stable symptomatic, and acute aortic syndromes.

Key Factors: Recommendations for diagnosis, genetic evaluation, family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease. Detailed guidelines on imaging techniques such as computed tomography, magnetic resonance imaging, echocardiography, and ultrasound. Emphasis on the role of multidisciplinary aortic teams and shared decision-making.

Analysis ^(1,4,12) : 

In summary, while all three articles highlight the importance and diagnostic accuracy of MRI, they differ in their specific focus areas, imaging techniques, and clinical scenarios. The shared conclusions emphasize MRI's non-invasive nature and its critical role in providing detailed anatomical and pathological information. The differing conclusions reflect the unique considerations and recommendations for using MRI in diagnosing aortic disease, plexopathy, and chest wall pain.

Shared Conclusions

• Importance of MRI: All three articles emphasize the importance of MRI in diagnosing various conditions. MRI is highlighted for its superior soft-tissue contrast and ability to provide detailed anatomical and pathological information.
• Non-invasive Nature: MRI is consistently noted for being a non-invasive imaging modality, making it a preferred choice for patients who need detailed imaging without the risks associated with invasive procedures.
• Diagnostic Accuracy: The articles agree on the high diagnostic accuracy of MRI in identifying and characterizing lesions, whether they are related to aortic disease, plexopathy, or chest wall pain.

References 

1.         Stowell JT, Walker CM, Chung JH, et al. ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain. Journal of the American College of Radiology. 2021;18(11):S394-S405. doi:10.1016/j.jacr.2021.08.004

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.

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