Compliance with the provisions in this policy may be monitored and addressed
through post payment data analysis and subsequent medical review audits.

**  
History/Background and/or General Information**  
  
Magnetic resonance angiography (MRA) is a non-invasive diagnostic test that is
an application of magnetic resonance imaging (MRI). By analyzing the amount of
energy released from tissues exposed to a strong magnetic field, MRA provides
images of normal and diseased blood vessels as well as visualization and
quantification of blood flow through these vessels.  
  
Please refer to the National Coverage Determination for MRI and MRA documented
in CMS Publication 100-03, _Medicare National Coverage Determinations  (NCD)
Manual,_ Chapter 1, Part 4, Section 220.2 Magnetic Resonance Imaging (MRI) for
coverage details.  
  
  
 ** _COVERED INDICATIONS_**  
  
 **I. _HEAD AND NECK_**  
  
Please refer to CMS Publication 100-03, _Medicare National Coverage
Determinations (NCD) Manual_ , Chapter 1, Part 4, Section 220.2.A.2 and
220.2.B.2 for coverage details and guidelines on the use of MRA of the head
and neck.  
  
MRA is appropriately used to verify the presence of a condition, suspected
because of findings from another test (usually an imaging study). For example,
a patient who presents with a transient ischemic attack (TIA) should not
undergo MRA simply because he might have a lesion which is amenable to
surgery. However, if that patient has a carotid bruit and is found by Doppler
study to have carotid stenosis, an MRA may be appropriate to evaluate the
stenotic section of artery for surgical intervention. Please note that the
anticipated surgery may be a percutaneous procedure such as carotid
angioplasty with stent insertion.  
  
Another patient may present with a headache; it is not appropriate to proceed
directly to MRA to rule out the possibility of an intracranial aneurysm.
However, if that patient was found to have a clinically significant amount of
blood in the cerebrospinal fluid, or the patient demonstrated signs and
symptoms strongly suggesting an unruptured intracranial aneurysm, an MRA (or
cerebral angiogram) may be appropriate.  
  
An MRA is not considered medically reasonable and necessary for screening
asymptomatic patients for intracranial aneurysms.  
  
 **II. _PERIPHERAL ARTERIES OF LOWER EXTREMITIES_**  
  
Please refer to CMS Publication 100-03, _Medicare National Coverage
Determinations (NCD)  Manual_, Chapter 1, Part 4, Section 220.2.B.2.b for
coverage details and guidelines on the use of MRA in the peripheral arteries
of the lower extremities.

  
**III. _ABDOMEN AND PELVIS_**  
  
Please refer to CMS Publication 100-03, _Medicare National Coverage
Determinations (NCD) Manual_ , Chapter 1, Part 4, Section 220.2.B.2.c for
coverage details and guidelines on the use of MRA in the pre-operative
evaluation of patients undergoing elective abdominal aortic aneurysm (AAA)
repair and imaging of the renal arteries and aortoiliac arteries in the
absence of AAA or aortic dissection.  
  
An MRA of the abdomen for evaluation of possible renal artery stenosis would
not be considered medically reasonable and necessary without some evidence
consistent with renovascular hypertension. Such evidence might include:

  * a history of early or late onset of hypertension, hypertension refractory to medication, or worsening renal function;
  * the presence of a renal artery bruit;
  * laboratory tests (elevated serum renins, increasing creatinine); or
  * other radiologic tests (ultrasound, captopril scintigraphy, or other imaging showing small kidney or unequal kidney sizes).

  
**IV. _CHEST_**  
  
 **Diagnosis of Pulmonary Embolism**  
  
Please refer to CMS Publication 100-03, _Medicare National Coverage
Determinations (NCD) Manual_ , Chapter 1, Part 4, Section 220.2.B.2.d.i for
coverage details and guidelines on the use of MRA in the diagnosis of
pulmonary embolism.  
  
 **Evaluation of Thoracic Aortic Dissection and Aneurysm**  
  
Please refer to CMS Publication 100-03, _Medicare National Coverage
Determinations (NCD)  Manual_, Chapter 1, Part 4, Section 220.2.B.2.d.ii for
coverage details and guidelines on the evaluation of thoracic aortic
dissection and aneurysm.  
  
 **NOTE:** This LCD does not address cardiac magnetic resonance imaging.  
  
 **Notice:** Services performed for any given diagnosis must meet all of the
indications and limitations stated in this policy, the general requirements
for medical necessity as stated in CMS payment policy manuals, any and all
existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services
performed outside of the reasonable and necessary requirements in this LCD.