Medical Policy

Heart MRI may be considered medically necessary for indications with Appropriate ACCF criteria with a Use Score between 7 and 9 (see table below):

Heart MRI (Appropriate ACCF et al. Criteria # with Use Score) A= Appropriate (7-9) U= Uncertain (4-6)	INDICATIONS . .
	Detection of CAD: Symptomatic
	Evaluation of Chest Pain Syndrome, Including Low Risk Unstable Angina (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)
2 U(4)	· Intermediate pre-test probability of CAD · ECG interpretable AND able to exercise
3 A(7)	· Intermediate pre-test probability of CAD · ECG uninterpretable OR unable to exercise
4 A(7-9)	· High pre-test probability of CAD
	Follow up of Known Ischemic CAD
	Asymptomatic or Stable Symptoms
4a A(7-9)	· ROUTINE FOLLOW-UP when last invasive or non-invasive assessment of coronary artery disease showed HEMODYNAMICALLY SIGNIFICANT CAD (ischemia on stress test or FFR less than or equal to 0.80 for a major vessel or stenosis greater than or equal to 70% of a major vessel) over two years ago, without supervening coronary revascularization, is an appropriate indication for stress CMR in patients with high risk clinical scenarios, such as left ventricular dysfunction (ejection fraction less than 50%) or severe un-revascularized multivessel CAD (if it will alter management), OR in patients with HIGH RISK OCCUPATIONS (e.g. associated with public safety, airline and boat pilots, bus and train drivers, bridge and tunnel workers/toll collectors, police officers, and firefighters) or a HIGH PERSONAL RISK (e.g. scuba divers, etc.).
	New, recurrent, or worsening (progressive) symptoms in patients with known ischemic CAD
4b A(7-9)	PRIOR LOW RISK CORONARY EVALUATION AT LEAST TWO YEARS EARLIER (e.g. limited extent of CORONARY ARTERY DISEASE, less than 5% myocardium at risk), AND NOW WITH NEW STABLE (or low risk unstable), RECURRENT, OR SLOWLY WORSENING (PROGRESSIVE) SYMPTOMS of coronary ischemia, is an appropriate indication for stress CMR in this patient group. However, regardless of timing of prior non-invasive assessment, clinical documentation of continued problematic symptoms or moderate to highly likely acute coronary syndrome (Table 6) of even low mortality risk (Table 7) is often better assessed with invasive coronary arteriography, particularly when stress testing in the last 2 years and current clinical findings are at odds. This category is very documentation-sensitive and requires judgment.
	Note: INVASIVE CORONARY ARTERIOGRAPHY IS GENERALLY PREFERABLE in those patients, who have a PRIOR MODERATE OR HIGH RISK STRESS TEST RESULT (especially if NOT previously evaluated by invasive coronary arteriography) or a current diagnosis of moderate to high risk UNSTABLE ANGINA, and inappropriate for repeat stress CMR unless supervening reasons to prefer a non-invasive approach are documented in the record (e.g. very unclear symptoms, CKD, dye allergy, etc.), and it could alter management.
	New or Worsening Symptoms without Known CAD
4c A(7-9)	One of the following, when invasive coronary arteriography is not clearly indicated or appropriate (e.g.data are equivocal, symptoms not clear, CKD, dye allergy, other etiologies suspect, etc.): Normal exercise EKG CCTA, invasive coronary arteriography, or stress imaging did not show obstructive CAD
4d U(4-6)	Abnormal prior stress imaging study, when invasive coronary arteriography is not clearly indicated or appropriate (e.g. data are equivocal, symptoms not clear, CKD, dye allergy, other etiologies suspect, etc.): Post Coronary Revascularization
4e A(7-9)	Symptomatic or ischemic equivalent that is well documented
4f A(7-9)	Asymptomatic
.	Minimum of 2 YEARS post coronary artery bypass grafting or 2 YEARS post percutaneous coronary intervention (whichever was the latter) is appropriate only for patients with high direct CORONARY-related risk, such as incomplete coronary revascularization with feasible additional revascularization of residual severe multivessel disease, need for otherwise unevaluated follow up of stenting of unprotected left main coronary artery (LM) disease or left ventricular dysfunction (ejection fraction less than 50%), OR for patients with HIGH OCCUPATIONAL RISK (e.g. associated with public safety, airline and boat pilots, bus and train drivers, bridge and tunnel workers/toll collectors, police officers, and firefighters) or HIGH PERSONAL RISK (e.g. scuba divers, etc.). Evaluation of Asymptomatic Patient
4g U(4-6)	High Global Risk CAD Regardless of EKG interpretability or ability to exercise greater than 2 years from last assessment
	Evaluation of Intra-Cardiac Structures (Use of MR Coronary Angiography)
8 A(8)	Evaluation of suspected coronary anomalies or coronary aneurysms
	Acute Chest Pain (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)
9 U(6)	With history of intermediate pre-test probability of CAD No ECG changes and serial cardiac enzymes negative
	Risk Assessment With Prior Test Results (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)
12 U(6)	Intermediate Global risk Equivocal stress imaging test (exercise, stress SPECT, or stress echo)
13 A(7)	Coronary angiography (catheterization or CCTA) Stenosis of unclear significance
13a A(7-9)	Prior Exercise EKG stress test or CCTA Equivocal result
13b A(7-9)	One of the following: High concern for ischemic EKG with intermediate to high global risk EKG, and indication for invasive coronary arteriography is not clear Abnormal prior exercise EKG with preference to avoid invasive evaluation (e.g. unclear symptoms, mildly abnormal stress EKG, dye allergy, CKD, etc.) Obstructive CAD on prior CCTA, and either physiologic evaluation for ischemia is required, or there are new or worsening symptoms. Obstructive CAD on invasive coronary angiography, and physiologic evaluation for ischemia is required LEFT BUNDLE BRANCH BLOCK, when the history (intermediate to high global risk), physical examination, and/or noninvasive ejection fraction together support further evaluation, and invasive coronary arteriography is not already indicated, is an indication for stress CMR
13c U(4-6)	One of the following: High concern for ischemic EKG, but only low global risk CORONARY ARTERY DISEASE, and indication for invasive coronary arteriography is not clear Abnormal prior stress imaging study, and indication for invasive coronary arteriography is not clear LEFT BUNDLE BRANCH BLOCK, when the history (low global risk), physical examination, and/or noninvasive ejection fraction together support further evaluation, and invasive coronary arteriography is not already indicated, is an indication for stress CMR
	Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery – Intermediate or High Risk Surgery (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)
15a A(7-9)	If all the following apply: Coronary evaluation before thoracoabdominal aortic surgery Patient has less than a 4 MET functional capacity Patient has one peri-operative risk factor No coronary evaluation (invasive or non-invasive) within the past year If invasive coronary arteriography is preferable, then stress CMR is not appropriate Alternatively, without the need for the above criteria, patient would be a candidate for stress CMR at the time of a preoperative evaluation if indications unrelated to the surgery were well documented in the clinical record
	Other Cardiovascular Conditions
15a A(7-9)	One of the following: Newly diagnosed systolic heart failure Newly diagnosed diastolic heart failure Sustained VT VF Exercise Induced VT or nonsustained VT Prior to initiation of antiarrhythmic therapy in high CAD global risk patients
15b U(4-6)	One of the following: Frequent PVCs (greater than 30/min) Intermediate or high Global Risk CAD
	Valvular Structure and Function
	Evaluation of Ventricular and Valvular Function
	Procedures may include LV/RV mass and volumes, MR angiography, quantification of valvular disease and delayed contrast enhancement, when echocardiogram is inadequate
18 A(9)	Assessment of complex congenital heart disease including anomalies of coronary circulation, great vessels, and cardiac chambers and valves
	Procedures may include LV/RV mass and volumes, MR angiography, quantification of valvular disease, and contrast enhancement
18a A(8)	Severe tricuspid regurgitation and suboptimal TTE images, for assessment of RV systolic function and systolic and diastolic volumes Alternative imaging modality: CCT (U(6)
18b A(7)	Severe MR suspected clinically, potentially underestimated on TTE despite optimal images; better imaging of MR jet needed Alternative imaging modality: TEE A(9)
18c A(7)	In chronic asymptomatic patient, to distinguish between moderate or severe primary MR, when TTE images are inadequate. Alternative imaging modality: TEE A(7)
18d A(7)	Discordance between clinical assessment and TTE about the severity of AR, when TTE images are inadequate. Alternative imaging modality: TTE A(8), CCT A(9)
18e A(7)	Pre TAVR assessment of aortic annular size and shape Alternative imaging modality: TEE A(7), CCT A(9)
18f A(7)	Pre TAVR assessment of aortic dimensions Alternative imaging modality: CCT A(9)
19 U(6)	Evaluation of LV function following myocardial infarction OR in heart failure patients
20 A(8)	Evaluation of LV function following myocardial infarction OR in heart failure patients Patients with technically limited images from echocardiogram
21 A(8)	Quantification of LV function Discordant information that is clinically significant from prior tests
22 A(8)	Evaluation of specific cardiomyopathies (infiltrative [amyloidosis, sarcoidosis, hemochromatosis,], noncompaction, HCM, acute viral myocarditis or due to cardiotoxic therapies), if echocardiography is inadequate and the information might alter management
	Use of delayed enhancement
23 A(8)	Characterization of native and prosthetic cardiac valves—including morphology of a bicuspid aortic valve’s ascending aorta, hemodynamics, planimetry of stenotic disease, quantification of regurgitant disease, preoperative/preinterventional evaluation of septal defects, and valve/inflow/outflow/conduit dimensions, necessary evaluation of congenital heart disease (e.g. anomalous pulmonary venous return, tetralogy of Fallot, etc.) Patients with technically limited images from echocardiogram, transesophageal echocardiogram, or cardiac CT
23a A(8)	Re-evaluation (less than 1 y) of the size and morphology of the aortic sinuses and ascending aorta in patients with a bicuspid AV and an ascending aortic diameter greater than 4 cm with 1 of the following: 1) aortic diameter greater than 4.5 cm 2) rapid rate of change in aortic diameter 3) family history (first-degree relative) of aortic dissection Alternative imaging modality: CCT A(8), TTE A(7)
23b A(7)	Characterization of bioprosthetic valve if suspected clinically significant valvular dysfunction and inadequate images from TTE and TEE. Alternative imaging modality: CCT A(7)
23c U(5)	Characterization of mechanical prosthetic valve if suspected clinically significant valvular dysfunction and inadequate images from TTE and TEE Alternative imaging modality: CCT A(7), Fluoroscopy A(7)
24 A(9)	Evaluation for arrhythmogenic right ventricular cardiomyopathy (ARVC) Patients presenting with syncope or ventricular arrhythmia
25 A(8)	Evaluation of myocarditis or myocardial infarction with normal coronary arteries Positive cardiac enzymes without obstructive atherosclerosis on angiography
	Evaluation of Intra- and Extra-Cardiac Structures
26 U(6)	Suspected cardiac mass, suspected tumor or thrombus, or potential cardiac source of emboli, when TTE images are inadequate Alternative imaging modality: TTE A(9), TEE A(7) Use of contrast for perfusion and enhancement
27 A(8)	Evaluation of pericardial conditions (pericardial mass, constrictive pericarditis, constriction versus restrictive cardiomyopathy)
28 A(8)	Evaluation for aortic dissection
29 A(8)	Evaluation of pulmonary veins prior to radiofrequency ablation for atrial fibrillation
	Left atrial and pulmonary venous anatomy including dimensions of veins for mapping purposes
	Detection of Myocardial Scar and Viability
	Evaluation of Myocardial Scar (Use of Late Gadolinium Enhancement)
30 A(7)	To determine the location, and extent of myocardial necrosis including “no reflow” regions. Post acute myocardial infarction
31 U(4)	To detect post PCI myocardial necrosis
32 A(9)	To determine viability prior to revascularization Establish likelihood of recovery of function with revascularization (PCI or CABG) or medical therapy
33 A(9)	To determine viability prior to revascularization Viability assessment by SPECT or dobutamine echo has provided "equivocal or indeterminate" results

Where Stress Echocardiography (SE) is noted as an appropriate substitute for a Cardiac MRI indication (#’s 2, 3, 4, 12, and 13 in above table) then at least ONE of the following contraindications to SE must be demonstrated:
- Stress echocardiography is not indicated; or
- Stress echocardiography has been performed however findings were inadequate, there were technical difficulties with interpretation, or results were discordant with previous clinical data; or
- Heart MRI is preferential to stress echocardiography including but not limited to following conditions:
  - Ventricular paced rhythm;
  - Evidence of ventricular tachycardia;
  - Severe aortic valve dysfunction;
  - Severe Chronic Obstructive Pulmonary Disease, (COPD) as defined as FEV1 less than 30% predicted or FEV1 less than 50% predicted plus respiratory failure or clinical signs of right heart failure. (GOLD classification of COPD access;
  - Congestive Heart Failure (CHF) with current Ejection Fraction (EF), 40%;
  - Inability to get an echo window for imaging;
  - Prior thoracotomy, (CABG, other surgery);
  - Obesity BMI greater than 40;
  - Poorly controlled hypertension [generally above 180 mm Hg systolic (both physical stress and dobutamine stress may exacerbate hypertension during stress echo)];
  - Poorly controlled atrial fibrillation (Resting heart rate greater than 100 bpm on medication);
  - Inability to exercise requiring pharmacological stress test;
  - Segmental wall motion abnormalities at rest (e.g. due to cardiomyopathy, recent MI, or pulmonary hypertension);
  - Arrhythmias with Stress Echocardiography ♦ - any patient on a type 1C anti- arrhythmic drug (i.e. Flecainide or Propafenone) or considered for treatment with a type 1C anti-arrhythmic drug.

Indications in ACCF guidelines with “Inappropriate” designation:

Heart MRI may be considered medically necessary when the individual meets ACCF Appropriate criteria for indications with an Inappropriate Score of 1-3 noted below, or meets any ONE of the following:

For any combination imaging study; or
For same imaging tests less than six weeks part unless specific guideline criteria states otherwise; or
For different imaging tests, such as CTA and MRA, of same anatomical structure less than six weeks apart without high level review to evaluate for medical necessity; or
For re-imaging of repeat or poor quality study.

Heart MRI (Appropriate ACCF et al. Criteria # with Use Score)	INDICATIONS	APPROPRIATE USE SCORE (1-3); I= Inappropriate
	Detection of CAD: Symptomatic
	Evaluation of Chest Pain Syndrome (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)
1	Low pre-test probability of CAD ECG interpretable AND able to exercise	I(2)
	Evaluation of Chest Pain Syndrome (Use of MR Coronary Angiography)
5	Intermediate pre-test probability of CAD ECG interpretable AND able to exercise	I(2)
6	Intermediate pre-test probability of CAD ECG uninterpretable OR unable to exercise	I(2)
7	High pre-test probability of CAD	I(1)
	Acute Chest Pain (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)
10	With history of high pre-test probability of CAD ECG - ST segment elevation and/or positive cardiac enzymes	I(1)
	Risk Assessment With Prior Test Results (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)
11	Normal prior stress test (exercise, nuclear, echo, MRI) High CHD risk (Framingham) Within 1 year of prior stress test	I(2)
	Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery – Low Risk Surgery (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)
14	Intermediate perioperative risk predictor	I(2)
	Detection of CAD: Post-Revascularization (PCI or CABG)
	Evaluation of Chest Pain Syndrome (Use of MR Coronary Angiography)
16	Evaluation of bypass grafts	I(2)
17	History of percutaneous revascularization with stents	I(1)