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 sites¹
• 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

• 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 Disease⁵

• Superior vena cava (SVC) syndrome⁶
• Subclavian Steal Syndrome after positive or inconclusive ultrasound when CTA/MRA are contraindicated or cannot be performed⁷
• Thoracic Outlet Syndrome when CTA/MRA are contraindicated or cannot be performed⁸
• 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 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 patients¹⁷
  • 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 procedure¹⁹
• Prior to catheter ablation in patients with atrial fibrillation²⁰

Post-operative/procedural Evaluation

• Post-surgical follow-up when records document medical reason requiring additional imaging
• After catheter ablation in patients with atrial fibrillation²⁰

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-1²¹) 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 weight limit/dimensions of MRI machine

References 

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, 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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