Policy 
INDICATIONS FOR CHEST MRI

The combination of superior soft tissue contrast and lack of ionizing radiation may make chest magnetic resonance imaging (MRI) preferable for the pediatric population or evaluation of the non-lung parenchyma. This must be weighed against a longer acquisition time and greater likelihood of artifact from patient motion. Chest computed tomography (CT) is generally better for lung evaluation. Chest magnetic resonance angiography (MRA) is ordered for evaluation of the intrathoracic blood vessels. Chest MRI and chest MRA should not be approved at the same time.

Chest Mass (non-lung parenchymal)
(Azizad, 2016; Carter, 2015, 2016, 2017; Hochhegger, 2011; Mullan, 2011)

• Mass or lesion, including lymphadenopathy, after non-diagnostic X-ray or ultrasound (chest CT indicated for pulmonary nodule)
• Thymoma screening in Myasthenia Gravis patients (Kumar, 2015)
• Congenital thoracic malformation on other imaging (chest X-ray, echocardiogram, gastrointestinal study, or inconclusive CT) (Ferreira, 2015; Hellinger, 2011; Karaosmanoglu, 2015; Poletto, 2017)

Chest Wall Pain (after initial evaluation with chest X-ray and/or rib series radiographs)

• History of known or suspected cancer
• Signs and symptoms of infection (non-lung parenchymal), such as:
  • Accompanying fever
  • Elevated inflammatory markers
  • Known infection at other sites
• Suspected muscle or tendon tear where imaging would change treatment

Brachial Plexopathy
(Mansukhani, 2013; Vijayasarathi, 2016). 

• If mechanism of injury or electromyography/nerve conduction velocity (EMG/NCV) studies are suggestive
• Chest MRI is preferred study, but neck and/or shoulder (upper extremity) MRI can be ordered depending on the suspected location of injury

Cystic Fibrosis
(Woods, 2020)

• Can be an alternative to chest CT to evaluate perfusion abnormalities, bronchiectasis, and mucus plugging if needed for treatment planning

Vascular Diseases are better evaluated with chest CTA or MRA
(ACR, 2019)

• Superior vena cava (SVC) syndrome (Friedman, 2017)
• Subclavian Steal Syndrome after positive or inconclusive ultrasound (Osiro, 2012; Potter, 2014)
• Thoracic Outlet Syndrome (ACR, 2014; Chavhan, 2017; Povlsen, 2018)
• Takayasu’s arteritis (Keser, 2014)
• Acute or chronic aortic dissection (ACR, 2017; Barman, 2014)
• Pulmonary hypertension — To evaluate for cause after echocardiogram or right heart catheterization (Ascha 2017, Rose-Jones 2015)

Congenital Malformations

• Congenital heart disease with pulmonary hypertension (Pascall 2018)
• Pulmonary sequestration (Sancak, 2003)

Atrial fibrillation with ablation planned
(Kolandaivelu 2012)

Preoperative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation

• Post-surgical follow-up when records document medical reason requiring additional imaging

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.

Overview 
MRI and Myasthenia Gravis — Myasthenia Gravis is a chronic autoimmune disease characterized by weakness of the skeletal muscles causing fatigue and exhaustion that is aggravated by activity and relieved by rest. It most often affects the ocular and other cranial muscles and is thought to be caused by the presence of circulating antibodies. Symptoms include ptosis, diplopia, chewing difficulties and dysphagia. Thymoma has a known association with myasthenia. Contrast-enhanced MRI may be used to identify the presence of a mediastinal mass suggestive of myasthenia gravis in patients with renal failure or allergy to contrast material.

MRI and Thoracic Outlet Syndrome — Thoracic outlet syndrome is a group of disorders involving compression at the superior thoracic outlet that affects the brachial plexus, the subclavian artery, and veins. It refers to neurovascular complaints due to compression of the brachial plexus or the subclavian vessels. Magnetic resonance multi-plane imaging shows bilateral images of the thorax and brachial plexus and can demonstrate the compression of the brachial plexus and venous obstruction.

MRI and Brachial Plexus — MRI is the only diagnostic tool that accurately provides high resolution imaging of the brachial plexus. The brachial plexus is formed by the cervical ventral rami of the lower cervical and upper thoracic nerves which arise from the cervical spinal cord, exit the bony confines of the cervical spine, and traverse along the soft tissues of the neck, upper chest, and course into the arms. 

References 

1. Azizad S, Sannananja B, Restrepo CS. Solid Tumors of the Mediastinum in Adults. Semin Ultrasound CT MR. Jun 2016;37(3):196-211. doi:10.1053/j.sult.2016.03.002
2. Carter BW, Benveniste MF, Betancourt SL, et al. Imaging Evaluation of Malignant Chest Wall Neoplasms. Radiographics. Sep-Oct 2016;36(5):1285-306. doi:10.1148/rg.2016150208
3. Carter BW, Benveniste MF, Truong MT, Marom EM. State of the Art: MR Imaging of Thymoma. Magn Reson Imaging Clin N Am. May 2015;23(2):165-77. doi:10.1016/j.mric.2015.01.005
4. Carter BW, Gladish GW. MR Imaging of Chest Wall Tumors. Magn Reson Imaging Clin N Am. May 2015;23(2):197-215. doi:10.1016/j.mric.2015.01.007
5. Carter BW, Betancourt SL, Benveniste MF. MR Imaging of Mediastinal Masses. Top Magn Reson Imaging. Aug 2017;26(4):153-165. doi:10.1097/rmr.0000000000000134
6. Hochhegger B, Marchiori E, Sedlaczek O, et al. MRI in lung cancer: a pictorial essay. Br J Radiol. Jul 2011;84(1003):661-8. doi:10.1259/bjr/24661484
7. Mullan CP, Madan R, Trotman-Dickenson B, Qian X, Jacobson FL, Hunsaker A. Radiology of chest wall masses. AJR Am J Roentgenol. Sep 2011;197(3):W460-70. doi:10.2214/ajr.10.7259
8. Kumar R. Myasthenia gravis and thymic neoplasms: A brief review. World J Clin Cases. Dec 16 2015;3(12):980-3. doi:10.12998/wjcc.v3.i12.980
9. Ferreira Tda A, Chagas IS, Ramos RT, Souza EL. Congenital thoracic malformations in pediatric patients: two decades of experience. J Bras Pneumol. Mar-Apr 2015;41(2):196-9. doi:10.1590/s1806-37132015000004374
10. Hellinger JC, Daubert M, Lee EY, Epelman M. Congenital thoracic vascular anomalies: evaluation with state-of-the-art MR imaging and MDCT. Radiol Clin North Am. Sep 2011;49(5):969-96. doi:10.1016/j.rcl.2011.06.013
11. Karaosmanoglu AD, Khawaja RD, Onur MR, Kalra MK. CT and MRI of aortic coarctation: pre- and postsurgical findings. AJR Am J Roentgenol. Mar 2015;204(3):W224-33. doi:10.2214/ajr.14.12529
12. Poletto E, Mallon MG, Stevens RM, CM A. Imaging Review of Aortic Vascular Rings and Pulmonary Sling. J Am Osteopath Coll Radiol. 2017;6(2):5-14.
13. Mansukhani KA. Electrodiagnosis in traumatic brachial plexus injury. Ann Indian Acad Neurol. Jan 2013;16(1):19-25. doi:10.4103/0972-2327.107682
14. Vijayasarathi A, Chokshi FH. MRI of the brachial plexus: A practical review. Appl Radiol. 2016;45(4):9-18.
15. Woods JC, Wild JM, Wielpütz MO, et al. Current state of the art MRI for the longitudinal assessment of cystic fibrosis. J Magn Reson Imaging. Nov 2020;52(5):1306-1320. doi:10.1002/jmri.27030
16. Zurkiya O, Ganguli S, Kalva SP, et al. ACR Appropriateness Criteria® Thoracic Outlet Syndrome. J Am Coll Radiol. May 2020;17(5s):S323-s334. doi:10.1016/j.jacr.2020.01.029
17. Friedman T, Quencer KB, Kishore SA, Winokur RS, Madoff DC. Malignant Venous Obstruction: Superior Vena Cava Syndrome and Beyond. Semin Intervent Radiol. Dec 2017;34(4):398-408. doi:10.1055/s-0037-1608863
18. Osiro S, Zurada A, Gielecki J, Shoja MM, Tubbs RS, Loukas M. A review of subclavian steal syndrome with clinical correlation. Med Sci Monit. May 2012;18(5):Ra57-63. doi:10.12659/msm.882721
19. Potter BJ, Pinto DS. Subclavian steal syndrome. Circulation. Jun 3 2014;129(22):2320-3. doi:10.1161/circulationaha.113.006653
20. Chavhan GB, Batmanabane V, Muthusami P, Towbin AJ, Borschel GH. MRI of thoracic outlet syndrome in children. Pediatr Radiol. Sep 2017;47(10):1222-1234. doi:10.1007/s00247-017- 3854-5
21. Povlsen S, Povlsen B. Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions. Diagnostics (Basel). Mar 20 2018;8(1)doi:10.3390/diagnostics8010021
22. Keser G, Direskeneli H, Aksu K. Management of Takayasu arteritis: a systematic review. Rheumatology (Oxford). May 2014;53(5):793-801. doi:10.1093/rheumatology/ket320
23. Barman M. Acute aortic dissection. ESC e-J Cardio Pract. 2014;12(25):02Jul2014. doi:https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-12/Acute- aortic-dissection
24. American College of Radiology. ACR Appropriateness Criteria® Thoracic Aorta Interventional Planning and Follow-up. American College of Radiology. Updated 2017. Accessed December 22, 2021. https://acsearch.acr.org/docs/3099659/Narrative/
25. Ascha M, Renapurkar RD, Tonelli AR. A review of imaging modalities in pulmonary hypertension. Ann Thorac Med. Apr-Jun 2017;12(2):61-73. doi:10.4103/1817-1737.203742
26. Rose-Jones LJ, McLaughlin VV. Pulmonary hypertension: types and treatments. Curr Cardiol Rev. 2015;11(1):73-9. doi:10.2174/1573403x09666131117164122
27. Pascall E, Tulloh RM. Pulmonary hypertension in congenital heart disease. Future Cardiol. Jul 2018;14(4):343-353. doi:10.2217/fca-2017-0065
28. Sancak T, Cangir AK, Atasoy C, Ozdemir N. The role of contrast enhanced three-dimensional MR angiography in pulmonary sequestration. Interact Cardiovasc Thorac Surg. Dec 2003;2(4):480-2. doi:10.1016/s1569-9293(03)00118-x
29. 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(2):523. doi:10.4022/jafib.523

Additional Resources

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.

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