Description
Magnetic resonance imaging shows the soft tissues and bones. With its multiplanar capabilities, high contrast, and high spatial resolution, it is an accurate diagnostic tool for conditions affecting the joint and adjacent structures. MRI can positively influence clinicians’ diagnoses and management plans for patients with conditions such as primary bone cancer, fractures, abnormalities in ligaments/tendons/cartilage, septic arthritis, and infection/inflammation.

OVERVIEW
*Conservative therapy — (musculoskeletal) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components such as rest, ice, heat, modified activities, medical devices, (including crutches, immobilizer, metal braces, orthotics, rigid stabilizer, or splints, etc. and not to include neoprene sleeves), medications, injections (bursal, and/or joint, not including trigger point), and diathermy, can be utilized. Active modalities may consist of physical therapy, a physician-supervised home exercise program**, and/or chiropractic care.

**Home exercise program (HEP) — The following two elements are required to meet guidelines for completion of conservative therapy:

• Information provided on exercise prescription/plan AND
• Follow up with member with information provided regarding completion of HEP (after suitable 4-week period), or inability to complete HEP due to physical reason, i.e., increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without explanation does not constitute “inability to complete” HEP).

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.

The American Academy of Pediatrics “Choosing Wisely” Guidelines advise against ordering advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory and plain radiographic examinations have been completed. “History, physical examination, and appropriate radiographs remain the primary diagnostic modalities in pediatric orthopedics, as they are both diagnostic and prognostic for the great majority of pediatric musculoskeletal conditions. Examples of such conditions would include, but not be limited to, the work up of injury or pain (spine, knees, and ankles), possible infection, and deformity. MRI examinations and other advanced imaging studies frequently require sedation in the young child (5 years old or less) and may not result in appropriate interpretation if clinical correlations cannot be made. Many conditions require specific MRI sequences or protocols best ordered by the specialist who will be treating the patient. If you believe findings warrant additional advanced imaging, discuss with the consulting orthopedic surgeon to make sure the optimal studies are ordered.”⁵⁶
 

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.
 

Policy  
INDICATIONS FOR UPPER EXTREMITY MRI (HAND, WRIST, ARM, ELBOW OR SHOULDER) (Plain
radiographs must precede MRI evaluation)

Some indications are for MRI, CT, or MR or CT arthrogram. More than one should not be approved at the same time.

If an MR arthrogram fits approvable criteria below, approve as MRI.

Joint or muscle pain without positive findings on an orthopedic exam as listed above, after X- ray completed^1,2 (does not apply to young children).

• Persistent joint or musculotendinous pain unresponsive to conservative treatment*, within the last 6 months which includes active medical therapy (physical therapy, chiropractic treatments, and/or physician-supervised exercise**), of at least four (4) weeks, OR
• With progression or worsening of symptoms during the course of conservative treatment

Joint specific approvable provocative orthopedic examination tests and suspected injuries

Note: With a positive orthopedic sign, an initial x-ray is always preferred. However, it is not required to approve advanced imaging. A positive sign is weakness or pain. Any test that suggests joint instability requires further imaging (list is not all inconclusive)

Shoulder^3,4,5,6

• Rotator cuff weakness on exam
• Subscapularis tendon tear
  • Belly press off test
  • Napoleon test
  • Bear Hug test
  • Internal rotation lag
  • Lift-off test
• Supraspinatus tendon tear
  • Drop Arm
  • Full Can test
  • Empty Can (aka Jobe or Supraspinatus test)
  • Hawkins or Neer tes7t (only when ordered by an orthopedic surgeon if there is clear documentation in the records that an actual rotator cuff tear is suspected, and NOT just for the evaluation of impingement)
• Infraspinatus / Teres Minor / Biceps tendon tear
  • External rotation lag sign at 0 and 90 degrees
  • Pain or weakness with resisted external rotation testing
  • Hornblower test
  • Popeye sign (if acute finding or for evaluation of surgical correction)
• Labral tear/ Instability
  • Grind test
  • Clunk test
  • Crank test, Compression-rotation test
  • O’Brien’s test
  • Anterior load and shift
  • Apprehension test
  • Posterior load and shift test
  • Jerk Test
  • Sulcus sign

Elbow8, 9

• Biceps tendon
  • Bicipital aponeurosis (BA) flex test
  • Biceps squeeze test
  • Hook test
  • Passive forearm pronation test
  • Reverse Popeye sign (if acute finding or for evaluation of surgical correction)
• Instability
  • Posterolateral rotatory drawer test
  • Tabletop relocation test
  • Valgus stress
  • Varus stress
  • Milking maneuver
  • Push-up test

Wrist10, 11

• Lunotriquetral ligament
  • Derby relocation test
  • Reagan test (lunotriquetral ballottement test)
• TFCC tear
  • Press test
  • Ulnar foveal sign/test
  • Ulnocarpal stress test
• Scaphoid ligament
  • Watson test (scaphoid shift test)
  • Scapholunate ballottement test

Tendon or Muscle Rupture after x-ray (not listed above)

• High clinical suspicion of a specific tendon rupture based on mechanism of injury and physical findings (i.e., triceps or pectorals tendon rupture)

Shoulder Dislocations12, 13

• Recurrent
• First time in any of the situations below that increase the risk or repeated dislocation
  • Glenoid or humeral bone loss on x-ray
  • Bankart lesion on radiographs14
  • 14-40 year-old15
  • > 40 with exam findings concerning for rotator cuff tear (i.e., weakness on exam)

Bone Fracture or Ligament Injury

• Suspected occult scaphoid fracture with snuffbox pain after initial x-ray
• Non scaphoid suspected occult, stress or insufficiency fracture with a negative initial x-ray16-18
  • Repeat x-rays in 10-14 days if negative or non-diagnostic
• Pathologic fracture on x-ray or CT19
• Suspected ligamentous/tendon injury with known fractures on x-ray/CT that may require surgery

Fracture Nonunion

• Nonunion or delayed union as demonstrated by no healing between two sets of x-rays. If a fracture has not healed by 4-6 months, there is delayed union. Incomplete healing by 6-8 months is nonunion. CT is the preferred study 20

Osteochondral Lesions (defects, fractures, osteochondritis dissecans) and x-ray completed21-24

• Clinical suspicion based on mechanism of injury and physical findings

Loose bodies or synovial chondromatosis and after x-ray or ultrasound completed

• In the setting of joint pain or mechanical symptoms 25

Osteonecrosis (e.g., Avascular necrosis (AVN))26-28

• To further characterize a prior abnormal x-ray or CT suggesting osteonecrosis
• Normal x-rays but symptomatic and high-risk (e.g., glucocorticosteroid use, renal transplant recipient, glycogen storage disease, alcohol abuse,29 sickle cell anemia30)
• Known osteonecrosis to evaluate a contralateral joint after initial x-rays

Joint prosthesis/replacement

• Suspected joint prosthesis loosening or dysfunction, (i.e., pseudotumor formation) after initial x-rays 31, 32

Extremity Mass33

• Mass or lesion after non-diagnostic x-ray or ultrasound14 CT is better than MRI to evaluate mass calcification or bone involvement and may complement or replace MRI34
  • If superficial mass, then ultrasound is the initial study
  • If deep mass, then x-ray is the initial study
• Vascular malformations
  • After initial evaluation with ultrasound and results will change management35
  • Inconclusive ultrasound
  • For preoperative planning
  • MRA is also approvable
  • Follow up after treatment/embolization

Known Primary Cancer of the Extremity36-40

• Initial staging primary extremity tumor
• Follow-up of known primary cancer of patient undergoing active treatment within the past year or as per surveillance imaging guidance for that cancer
• Signs or symptoms or imaging findings suspicious for recurrence
• Suspected metastatic disease with signs/symptoms and after initial imaging with radiographs

Further evaluation of indeterminate or questionable 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 (i.e., x-ray, ultrasound or MRI) 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.)

Infection of Bone, Joint or Soft tissue abscess41-43

• Abnormal x-ray or ultrasound
• Negative x-ray or ultrasound but with a clinical suspicion of infection based on either of the following:
  • Signs and symptoms of joint or bone infection include:
    • Pain and swelling
    • Decrease range of motion
    • Fever
  • Laboratory findings of infection include any of the following:
    • Elevated ESR or CRP
    • Elevated white blood cell count
    • Positive joint aspiration
• Ulcer (diabetic, pressure, ischemic, traumatic) with signs of infection (redness, warm, swelling, pain, discharge which may range from white to serosanguineous) that is not improving despite treatment and bone, or deep infection is suspected
  • Increased suspicion if size or temperature increases, bone is exposed/positive probe-to-bone test, new areas of breakdown, new smell44

Pre-operative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation

• When imaging, physical or laboratory findings indicate joint infection, delayed or non- healing or other surgical/procedural complications.

For evaluation of known or suspected autoimmune disease (e.g., rheumatoid arthritis)45, 46

• Further evaluation of an abnormality or non-diagnostic findings on prior imaging
• Initial imaging of a single joint for diagnosis or response to therapy after plain films and appropriate lab tests (e.g., RF, ANA, CRP, ESR)
• To determine change in treatment or when diagnosis is uncertain prior to start of treatment
• Follow-up to determine treatment efficacy in the following:
  • Early rheumatoid arthritis
  • Advanced rheumatoid arthritis if x-ray and ultrasound are equivocal or non- contributory

Foreign Body47

• Indeterminate x-ray and ultrasound

Peripheral Nerve Entrapment (e.g., carpal tunnel)48-52

• Abnormal electromyogram or nerve conduction study
• Abnormal x-ray or ultrasound
• Clinical suspicion and failed 4 weeks conservative treatment including at least two of the following (active treatment with physical therapy is not required):
  • Activity modification
  • Rest, ice, or heat
  • Splinting or orthotics
  • Medication

Brachial Plexopathy53, 54

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

Pediatrics

• Chronic Recurrent Multifocal Osteomyelitis after initial work-up (labs (i.e. CRP/ESR and x-ray).55 (Whole body Bone Marrow MRI is more appropriate when multiple joints requested see NIA_CG_059)

References

43. Glaudemans A, Jutte PC, Cataldo MA, et al. Consensus document for the diagnosis of peripheral bone infection in adults: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging. Apr 2019;46(4):957-970. doi:10.1007/s00259-019- 4262-x
44. Bowers S, Franco E. Chronic Wounds: Evaluation and Management. Am Fam Physician. Feb 1 2020;101(3):159-166.
45. Colebatch AN, Edwards CJ, Østergaard M, et al. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Ann Rheum Dis. Jun 2013;72(6):804-14. doi:10.1136/annrheumdis-2012-203158
46. Narváez JA, Narváez J, De Lama E, De Albert M. MR imaging of early rheumatoid arthritis. Radiographics. Jan 2010;30(1):143-63; discussion 163-5. doi:10.1148/rg.301095089
47. Laya BF, Restrepo R, Lee EY. Practical Imaging Evaluation of Foreign Bodies in Children: An Update. Radiol Clin North Am. Jul 2017;55(4):845-867. doi:10.1016/j.rcl.2017.02.012
48. Domkundwar S, Autkar G, Khadilkar SV, Virarkar M. Ultrasound and EMG-NCV study (electromyography and nerve conduction velocity) correlation in diagnosis of nerve pathologies. J Ultrasound. Jun 2017;20(2):111-122. doi:10.1007/s40477-016-0232-3
49. Dong Q, Jacobson JA, Jamadar DA, et al. Entrapment neuropathies in the upper and lower limbs: anatomy and MRI features. Radiol Res Pract. 2012;2012:230679. doi:10.1155/2012/230679
50. Donovan A, Rosenberg ZS, Cavalcanti CF. MR imaging of entrapment neuropathies of the lower extremity. Part 2. The knee, leg, ankle, and foot. Radiographics. Jul-Aug 2010;30(4):1001-19. doi:10.1148/rg.304095188
51. Meyer P, Lintingre PF, Pesquer L, Poussange N, Silvestre A, Dallaudière B. The Median Nerve at the Carpal Tunnel … and Elsewhere. J Belg Soc Radiol. Jan 31 2018;102(1):17. doi:10.5334/jbsr.1354
52. Tos P, Crosio A, Pugliese P, Adani R, Toia F, Artiaco S. Painful scar neuropathy: principles of diagnosis and treatment. Plastic and Aesthetic Research. 2015;2:156-164. doi:10.4103/2347- 9264.160878
53. Mansukhani KA. Electrodiagnosis in traumatic brachial plexus injury. Ann Indian Acad Neurol. Jan 2013;16(1):19-25. doi:10.4103/0972-2327.107682
54. Vijayasarathi A, Chokshi FH. MRI of the brachial plexus: A practical review. Appl Radiol. 2016;45(4):9-18.
55. Zhao DY, McCann L, Hahn G, Hedrich CM. Chronic nonbacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO). J Transl Autoimmun. 2021;4:100095. doi:10.1016/j.jtauto.2021.100095
56. American Academy of Pediatrics. Five things physicians and patients should question: Do not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory and plain radiographic examinations have been completed. Choosing Wisely Initiative ABIM Foundation. Updated February 12, 2018. Accessed November 20, 2022. https://www.choosingwisely.org/clinician-lists/aap-posna-mri-or-ct-for- musculoskeletal-conditions-in-children/

Coding section

Codes	Number	Description
CPT	73218	Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast material(s)
	73219	With contrast material(s)
	73220	Without contrast material(s), followed by contrast material(s) and further sequences
	73221	Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s)
	73222	With contrast material(s)
	73223	Without contrast material(s), followed by contrast material(s) and further sequences
	0698T	Annual review, updating entire policy. Adding general information statement and evaluation of indeterminate findings on prior imaging. Clarifying pathological reflexes and cerebellar ataxia. Removing radicular pain and malaise from isolated back pain in pediatric population.

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.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2019 Forward 

12/07/2023	Annual review, updating entire policy for clarity. Adding verbiage for indeterminate findings, vascular malformations, known AVN, indications not addressed in this policy and Popeye and reverse Popeye
12/19/2022	Annual review, no change to policy intent. Updating policy for clarity and specificity.
12/02/2021	Annual review, added verbiage about impingement, non traumatic shoulder instability and glenoid labral tear requiring active conservative therapy. Also added detail regarding shoulder dislocation; suspected bone infection in the setting of ulcers and neuropahty; brachial plexopathy and treatment for rheumatoid arthritis. Also updating description and references.
12/01/2020	Annual review, added verbiage regarding adhesive capsulitis, clarified policy verbiage. Also updated description and references.
12/16/2019	NEW POLICY