Description
Magnetic resonance angiography (MRA) is a noninvasive alternative to catheter angiography for evaluation of vascular structures in the upper extremity. Magnetic resonance venography (MRV) is used to image veins instead of arteries. MRA and MRV are less invasive than conventional X-ray digital subtraction angiography.

OVERVIEW
UPPER EXTREMITY DVT — "Secondary DVT of the upper extremity is by far the most common type. Indwelling venous devices such as catheters, pacemakers, and defibrillators put patients at the highest risk of thrombus. Central venous catheters, which are difficult to place, such as those requiring multiple insertion attempts, are noted to have increased incidence of associated thrombus [9]. Other risk factors associated with higher likelihood of UEDVT include advanced age, previous thrombophlebitis, postoperative state, hypercoagulability, heart failure, cancer, right-heart procedures, and intensive care unit admissions" (ACR, 2014).

MRA/MRV and Raynaud’s Syndrome — Raynaud’s syndrome is evidenced by episodic waxy pallor or cyanosis of the fingers caused by vasoconstriction of small arteries or arterioles in the fingers. It usually occurs due to a response to cold or to emotional stimuli. MRA may be used in the evaluation of Raynaud’s syndrome.

MRA/MRV and Stenosis or Occlusion — MRA of the central veins of the chest is used for the detection of central venous stenoses and occlusions. High-spatial resolution MRA characterizes the general morphology and degree of stenosis. Enlarged and well-developed collateral veins in combination with the non-visualization of a central vein may be indicative of chronic occlusion, whereas less-developed or absent collateral veins are suggestive of acute occlusions. A hemodynamically significant stenosis may be indicated by the presence of luminal narrowing with local collaterals (Conte, 2019; Kim, 2008). 

MRA and Arterial Obstructive Disease — Catheter angiography is the standard of reference for assessing arterial disease but MRA with contrast enhanced media has gained acceptance and can image the entire vascular system. Contrast agents such as high dose gadolinium have been associated with the development of nephrogenic systemic fibrosis in patients with chronic renal insufficiency, but newer agents are safer in this regard. Gadolinium dosage may be decreased without compromising image quality in high-spatial-resolution contrast-enhanced MRA of the upper extremity.  

Policy
UPPER EXTREMITY MRA/MRV Is considered MEDICALLY NECESSARY for the following indications:

INDICATIONS FOR UPPER EXTREMITY MRA/MRV

Hand Ischemia^1-3

• Arterial Doppler not needed with any of these acute symptoms:
  • Ischemic ulceration without segmental temperature change
  • Ischemic ulceration with painful ischemia
  • Acute sustained loss of perfusion with or without acral ulceration
  • Imminent loss of digit
• Clinical symptoms without the above features, arterial Doppler abnormal and will change management
  • Includes Raynaud’s (can be associated with scleroderma), Buerger disease, and other vasculopathies4
• Clinical concern for vascular cause of ulcers with abnormal or indeterminate ultrasound5
• After stenting or surgery with signs of recurrence or indeterminate ultrasound6

Deep Venous Thrombosis or Embolism^{7, 8}

• After abnormal ultrasound of arm veins if it will change management, or negative or indeterminate ultrasound to rule out other causes
• For evaluation of central veins
• Clinical suspicion of upper arterial emboli^{9, 10}

Clinical suspicion of vascular disease with abnormal or indeterminate ultrasound or other imaging^{9, 10}

• Tumor invasion^{11, 12}
• Trauma¹³
• Vasculitis^{2, 14}
• Aneurysm¹⁵

* National Imaging Associates, Inc. (NIA) is a subsidiary of Magellan Healthcare, Inc.
 

• Stenosis/occlusions¹⁶

Vascular Malformation^{17, 18}

• Non-diagnostic doppler ultrasound

Traumatic injuries with clinical findings suggestive of arterial injury – CTA preferred emergently¹³

Assessment/evaluation of known vascular disease/condition

Pre-operative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure¹⁹

Post-operative/procedural evaluations

• A 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.

Special Circumstances²⁰

• High suspicion of an acute arterial obstruction — Arteriography preferred (the gold standard)
• Renal impairment
  • Not on dialysis
    • Mild to moderate, GFR 30-45 ml/min MRA with contrast can be performed
    • Severe, GFR < 30 ml/min MRA without contrast
  • On dialysis
    • CTA with contrast can be performed
• Doppler ultrasound can be useful in evaluating bypass grafts

All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.

References

1. Ahmed O, Hanley M, Bennett SJ, et al. American College of Radiology ACR Appropriateness Criteria^® - Vascular Claudication: Assessment for Revascularization. J Am Coll Radiol. May 2017; 14(5 Suppl):S372-379. https://acsearch.acr.org/docs/69411/Narrative/. Published 2017.
2. Bae M, Chung SW, Lee CW, et al. Upper limb ischemia: Clinical experiences of acute and chronic upper limb ischemia in a single Center. Korean J Thorac Cardiovasc Surg. 2015; 48(4):246–251. doi:10.5090/kjtcs.2015.48.4.246.
3. Bozlar U, Ogur T, Norton P, et al. CT angiography of the upper extremity arterial system: Part 1-anatomy, technique, and use in trauma patients. AJR Am J Roentgenol. 2013a; 201(4):745-752
4. Bozlar U, Ogur T, Norton P, et al. CT angiography of the upper extremity arterial system: Part 2-clinical applications beyond trauma patients. AJR Am J Roentgenol. 2013b; 201(4):753-763.
5. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb=threatening ischemia. J Vasc Surg. 2019 Jun; 69(6S):3S-1255.e40. Epub 2019 May 28.
6. Dill KE, Bennett SJ, Hanley M, et al. American College of Radiology ACR Appropriateness Criteria^® - Upper Extremity Swelling. https://acsearch.acr.org/docs/69417/Narrative/. Published 2014.
7. Fonseka CL, Galappaththi SR, Abeyaratne D, et al. A case of polyarteritis nodosa presenting as rapidly progressing intermittent claudication of right leg. Case Reports in Medicine. 2017; 017, Article ID 4219718.
8. Heil J, Miesbach W, Vogl T, et al. Deep vein thrombosis of the upper extremity. Dtsch Arztebl Int. 2017; 114(14):244–249.
9. Hotchkiss R, Marks T. Management of acute and chronic vascular conditions of the hand. Curr Rev Musculoskelet Med. 2014; 7(1):47–52.
10. Jin T, Wu G, Li X, et. al. Evaluation of vascular invasion in patients with musculoskeletal tumors of lower extremities: Use of time-resolved 3D MR angiography at 3-T. Acta Radiol. 2018 May; 59(5):586-592. 
11. Kransdorf MJ, Murphey MD, Wessell DE, et al. American College of Radiology ACR Appropriateness Criteria^® - Soft Tissue Masses. https://acsearch.acr.org/docs/69434/Narrative/. Published 2017.
12. Lebowitz C, Matzon JL. Arterial injury in the upper extremity evaluation, strategies, and anticoagulation management. Hand Clin. 2018; 34(1):85-95.
13. Madani H, Farrant J, Chhaya N, et al. Peripheral limb vascular malformations: An update of appropriate imaging and treatment options of a challenging condition. Br J Radiol. 2015; 88(1047):20140406.
14. McMahan ZH, Wigley FM. Raynaud’s phenomenon and digital ischemia: A practical approach to risk stratification, diagnosis and management. Int J Clin Rheumtol. 2010; 5(3):355-70.
15. Menke J, Larsen J. Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease. Ann Intern Med. 2010; 153(5):325-334. doi: 10.7326/0003-4819-153-5-201009070-00007.
16. Nguyen N, Sharma A, West JK, et al. Presentation, clinical features, and results of intervention in upper extremity fibromuscular dysplasia. J Vasc Surg. 2017 Aug; 66(2):554-563.
17. Obara P, McCool J, Kalva SP, et al. ACR Appropriateness Criteria clinically suspected vascular malformation of the extremities. J Am Coll Radiol. 2019 Nov; 16(11S):S340-S347.  
18. Pollak AW, Norton P, Kramer CM. Multimodality imaging of lower extremity peripheral arterial disease: Current role and future directions. Circ Cardiovasc Imaging. 2012 Nov 1; 5(6):797–807.
19. Rosyd FN. Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer. Int J Res Med Sci. 2017 Oct; 5(10):4206-4213.
20. Sharma AM, Norton PT, Zhu D. Conditions presenting with symptoms of peripheral arterial disease. Semin Intervent Radiol. 2014; 31(4):281-291. http://doi.org/10.1055/s-0034-1393963.
21. Verikokos C, Karaolanis G, Doulaptsis M, et al. Giant popliteal artery aneurysm: case report and review of the literature. Case Rep Vasc Med. 2014; 2014:780561.
22. Wani ML, Ahangar AG, Ganie FA, et al. Vascular injuries:Trends in management. Trauma Mon. 2012; 17(2):266–269.
23. Wong VW, Major MR, Higgins JP. Nonoperative management of acute upper limb ischemia. Hand (NY). 2016; 11(2):131–143. doi:10.1177/1558944716628499.

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 non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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