Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Cardiovascular Magnetic Resonance (CMR) Page 1 of 16 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Cardiovascular Magnetic Resonance (CMR) Professional Institutional Original Effective Date: August 4, 2005 Original Effective Date: July 1, 2006 Revision Date(s): February 27, 2006, Revision Date(s):May 2, 2007; May 2, 2007; November 1, 2007; November 1, 2007; January 1, 2010; January 1, 2010; February 15, 2013; February 15, 2013; December 11, 2013; December 11, 2013; April 15, 2014 April 15, 2014; July 15, 2014; July 15, 2014; June 10, 2015; June 10, 2015; June 8, 2016; June 8, 2016; October 1, 2016; October 1, 2016; May 10, 2017 May 10, 2017 Current Effective Date: July 15, 2014 Current Effective Date: July 15, 2014 State and Federal mandates and health plan member contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service. The BCBSKS Medical Policies contained herein are for informational purposes and apply only to members who have health insurance through BCBSKS or who are covered by a self-insured group plan administered by BCBSKS. Medical Policy for FEP members is subject to FEP medical policy which may differ from BCBSKS Medical Policy. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents of Blue Cross and Blue Shield of Kansas and are solely responsible for diagnosis, treatment and medical advice. If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan. DESCRIPTION Cardiovascular magnetic resonance (CMR) is established in clinical practice for the diagnosis and management of disorders of the cardiovascular system. CMR has several advantages over other imaging modalities: Non-invasive No ionizing radiation No known clinical side effects

Cardiovascular Magnetic Resonance (CMR) Page 2 of 16 Soft tissue imaging is superior No imaging artifact from bone Equal clarity in any view: axial, sagittal, coronal, or oblique Ability to acquire two, three, and four-dimensional data Disadvantages of CMR include: Requires more patient cooperation Longer imaging times Incompatibility with various medical and life support devices Attraction of ferromagnetic objects Cost (When applied appropriately with state of the art MRI technology and expertise, initial test cost may be offset by a reduction in downstream utilization of other redundant imaging tests. CMR has the potential to provide a comprehensive examination in one setting at considerably less risk and cost to the patient.)

Cardiovascular Magnetic Resonance (CMR) Page 3 of 16 POLICY A. Medically necessary indications for CMR include: 1. Congenital heart disease a. Assessment of shunt size b. Situs anomalies with complex congenital heart disease c. Anomalous pulmonary venous return, especially in complex anomalies and cor triatriatum d. Anomalous systemic venous return e. Systemic or pulmonary venous obstruction f. Ventricular Septal Defect (VSD) associated with complex anomalies g. Supracristal VSD h. Evaluation of right and left ventricular volumes, mass and function i. Pulmonary regurgitation j. Supravalvular aortic stenosis k. Post-operative follow-up of shunts l. Aortic (sinus Valsalva) aneurysm m. Aortic coarctation n. Vascular rings o. Aortopulmonary window p. Anomalous origin of coronary arteries q. Pulmonary atresia r. Central pulmonary stenosis s. Systemic to pulmonary collaterals 2. Acquired diseases of the vessels a. Diagnosis and follow-up of thoracic and abdominal aortic aneurysm including Marfan disease b. Diagnosis and follow-up of chronic aortic dissection c. Diagnosis of aortic intramural hemorrhage d. Diagnosis of penetrating ulcers of the aorta e. Pulmonary artery anatomy and flow f. Assessment of thoracic, abdominal and pelvic veins g. Assessment of renal arteries h. Assessment of iliac, femoral and lower leg arteries i. Assessment of thoracic great vessel origins j. Assessment of cervical carotid arteries k. Assessment of pulmonary veins including one in association with an electrophysiology ablation for atrial fibrillation 3. Coronary artery disease a. Assessment of global ventricular (left and right) function and mass b. Coronary anomalies c. Acute and chronic myocardial infarction - detection and assessment; myocardial viability

Cardiovascular Magnetic Resonance (CMR) Page 4 of 16 4. Pericardial disease, cardiac tumors, cardiomyopathies and cardiac transplants a. Detection and characterization of cardiac and pericardiac tumors b. Hypertrophic cardiomyopathy c. Dilated cardiomyopathy - differentiation from dysfunction related to coronary artery disease d. Arrhythmogenic right ventricular cardiomyopathy (dysplasia) e. Siderotic cardiomyopathy (in particular thalassemia) f. Restrictive cardiomyopathy 5. Valvular heart disease a. Cardiac chamber anatomy and function b. Quantification of regurgitation or stenosis B. Experimental / investigational indications: 1. CMR as a screening test 2. Coronary MRA for screening of coronary artery disease C. Subject to review for medical necessity: 1. CMR for indications that are not listed above 2. Duplication of services such as CT scan, radionuclide studies, ultrasound, and MRI CODING The following codes for treatment and procedures applicable to this policy are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement. Please refer to the member's contract benefits in effect at the time of service to determine coverage or noncoverage of these services as it applies to an individual member. CPT/HCPCS 75557 Cardiac magnetic resonance imaging for morphology and function without contrast material; 75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging 75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; 75563 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)

Cardiovascular Magnetic Resonance (CMR) Page 5 of 16 ICD-9 Diagnoses Diagnoses are otherwise subject to medical policy as stated above 093.0 Cardiovascular syphilis; Aneurysm of aorta, specified as syphilitic 093.1 Cardiovascular syphilis; Syphilitic aortitis 093.20 Syphilitic endocarditis; valve, unspecified 093.21 Syphilitic endocarditis; mitral valve 093.22 Syphilitic endocarditis; aortic valve 093.23 Syphilitic endocarditis; tricuspid valve 093.24 Syphilitic endocarditis; pulmonary valve 093.81 Other specified cardiovascular syphilis; syphilitic pericarditis 093.82 Other specified cardiovascular syphilis; syphilitic myocarditis 093.89 Other specified cardiovascular syphilis; other 093.9 Cardiovascular syphilis, unspecified 162.2 Malignant neoplasm of trachea, bronchus, and lung; main bronchus 162.3 Malignant neoplasm of trachea, bronchus, and lung; upper lob, bronchus or lung 162.4 Malignant neoplasm of trachea, bronchus, and lung; middle lobe, bronchus or lung 162.5 Malignant neoplasm of trachea, bronchus, and lung; lower lobe, bronchus or lung 162.8 Malignant neoplasm of trachea, bronchus, and lung; other parts of bronchus or lung 162.9 Malignant neoplasm of trachea, bronchus, and lung; bronchus and lung, unspecified 163.0 Malignant neoplasm of pleura; parietal pleura 163.1 Malignant neoplasm of pleura; visceral pleura 163.8 Malignant neoplasm of pleura; other specified sites of pleura 163.9 Malignant neoplasm of pleura; pleura, unspecified 164.1 Malignant neoplasm of bronchus, lung, pleura, thymus, heart, and mediastinum; heart 164.2 Malignant neoplasm of bronchus, lung, pleura, thymus, heart, and mediastinum; anterior mediastinum 164.3 Malignant neoplasm of bronchus, lung, pleura, thymus, heart, and mediastinum; posterior mediastinum 164.8 Malignant neoplasm of bronchus, lung, pleura, thymus, heart, and mediastinum; other 164.9 Malignant neoplasm of bronchus, lung, pleura, thymus, heart, and mediastinum; mediastinum, part unspecified 171.4 Malignant neoplasm of connective and other soft tissue; thorax 197.0 Secondary malignant neoplasm of respiratory and digestive systems; lung 197.1 Secondary malignant neoplasm of respiratory and digestive systems; mediastinum 197.2 Secondary malignant neoplasm of respiratory and digestive systems; pleura 212.3 Benign neoplasm of respiratory and intrathoracic organs; bronchus and lung 212.4 Benign neoplasm of respiratory and intrathoracic organs; pleura 212.5 Benign neoplasm of respiratory and intrathoracic organs; mediastinum 212.6 Benign neoplasm of respiratory and intrathoracic organs; thymus 212.7 Benign neoplasm of respiratory and intrathoracic organs; heart 214.2 Lipoma; intrathoracic organs 215.4 Other benign neoplasm of connective and other soft tissue; thorax 235.7 Neoplasm of uncertain behavior of digestive and respiratory systems; trachea, bronchus, and lung 235.8 Neoplasm of uncertain behavior of digestive and respiratory systems; pleura, thymus, and mediastinum

Cardiovascular Magnetic Resonance (CMR) Page 6 of 16 390 Rheumatic fever without mention of heart involvement 391.0 Rheumatic fever with heart involvement; acute rheumatic pericarditis 391.1 Rheumatic fever with heart involvement; acute rheumatic endocarditis 391.2 Rheumatic fever with heart involvement; acute rheumatic myocarditis 391.8 Rheumatic fever with heart involvement; other acute rheumatic heart disease 391.9 Rheumatic fever with heart involvement; acute rheumatic heart disease, unspecified 392.0 Rheumatic chorea; with heart involvement 392.9 Rheumatic chorea; without mention of heart involvement 393 Chronic rheumatic pericarditis 394.0 Diseases of mitral valve; mitral stenosis 394.1 Diseases of mitral valve; rheumatic mitral insufficiency 394.2 Diseases of mitral valve; mitral stenosis with insufficiency 394.9 Diseases of mitral valve; other and unspecified mitral valve diseases 395.0 Diseases of aortic valve; rheumatic aortic stenosis 395.1 Diseases of aortic valve; rheumatic aortic insufficiency 395.2 Diseases of aortic valve; rheumatic aortic stenosis with insufficiency 395.9 Diseases of aortic valve; other and unspecified rheumatic aortic diseases 396.0 Diseases of mitral and aortic valves; mitral valve stenosis and aortic valve stenosis 396.1 Diseases of mitral and aortic valves; mitral valve stenosis and aortic valve 396.2 Diseases of mitral and aortic valves; mitral valve insufficiency and aortic valve 396.3 Diseases of mitral and aortic valves; mitral valve insufficiency and aortic valve insufficiency 396.8 Diseases of mitral and aortic valves; multiple involvement of mitral and aortic valves 396.9 Diseases of mitral and aortic valves; mitral and aortic valve diseases, unspecified 397.0 Diseases of other and endocardial structures; diseases of tricuspid valve 397.1 Diseases of other and endocardial structures; rheumatic diseases of pulmonary valve 397.9 Diseases of other and endocardial structures; rheumatic diseases of endocardium, valve unspecified 398.0 Other rheumatic heart disease; rheumatic myocarditis 398.90 Other and unspecified rheumatic heart diseases; rheumatic heart disease, unspecified 398.91 Other and unspecified rheumatic heart diseases; rheumatic heart failure (congestive) 398.99 Other and unspecified rheumatic heart diseases; other 410.00 Acute myocardial infarction of anterolateral wall, episode of care unspecified 410.01 Acute myocardial infarction of anterolateral wall, initial episode of care 410.02 Acute myocardial infarction of anterolateral wall, subsequent episode of care 410.10 Acute myocardial infarction of other anterior wall, episode of care unspecified 410.11 Acute myocardial infarction; of other anterior wall, initial episode of care 410.12 Acute myocardial infarction of other anterior wall, subsequent episode of care 410.20 Acute myocardial infarction of inferolateral wall, episode of care unspecified 410.21 Acute myocardial infarction of inferolateral wall, initial episode of care 410.22 Acute myocardial infarction of inferolateral wall, subsequent episode of care 410.30 Acute myocardial infarction of inferoposterior wall, episode of care unspecified 410.31 Acute myocardial infarction of inferoposterior wall, initial episode 410.32 Acute myocardial infarction of inferoposterior wall, subsequent episode of care 410.40 Acute myocardial infarction of other inferior wall, episode of care unspecified

Cardiovascular Magnetic Resonance (CMR) Page 7 of 16 410.41 Acute myocardial infarction of other inferior wall, initial episode of care 410.42 Acute myocardial infarction of other inferior wall, subsequent episode of care 410.50 Acute myocardial infarction of other lateral wall, episode of care unspecified 410.51 Acute myocardial infarction of other lateral wall, initial episode of care 410.52 Acute myocardial infarction of other lateral wall, subsequent episode of care 410.60 Acute myocardial infarction, true posterior wall infarction, episode of care unspecified 410.61 Acute myocardial infarction, true posterior wall infarction, initial episode of care 410.62 Acute myocardial infarction, true posterior wall infarction, subsequent episode of care 410.70 Acute myocardial infarction, subendocardial infarction, episode of care unspecified 410.71 Acute myocardial infarction, subendocardial infarction, initial episode of care 410.72 Acute myocardial infarction, subendocardial infarction, subsequent episode of care 410.80 Acute myocardial infarction of other specified sites, episode of care unspecified 410.81 Acute myocardial infarction of other specified sites, initial episode of care 410.82 Acute myocardial infarction of other specified sites, subsequent episode of care 410.90 Acute myocardial infarction, unspecified, episode of care unspecified 410.91 Acute myocardial infarction, initial episode of care 410.92 Acute myocardial infarction of other specified sites, subsequent episode of care 411.0 Other acute and subacute forms of ischemic heart disease; postmyocardial infarction syndrome 411.1 Other acute and subacute forms of ischemic heart disease; intermediate coronary syndrome 411.81 Other acute and subacute forms of ischemic heart disease; acute coronary occlusion without myocardial infarction 411.89 Other acute and subacute forms of ischemic heart disease; other 415.11 Pulmonary embolism and infarction; iatrogenic pulmonary embolism and infarction 415.12 Pulmonary embolism and infarction; septic pulmonary embolism 415.19 Pulmonary embolism and infarction; other 417.0 Other diseases of pulmonary circulation; arteriovenous fistula of pulmonary vessels 417.1 Other diseases of pulmonary circulation; aneurysm of pulmonary artery 417.8 Other diseases of pulmonary circulation; other specified diseases of pulmonary circulation 420.0 Acute pericarditis; in diseases classified elsewhere 420.90 Other and unspecified acute pericarditis; acute pericarditis, unspecified` 420.91 Other and unspecified acute pericarditis; acute idiopathic pericarditis 420.99 Other and unspecified acute pericarditis; other 421.0 Acute and subacute endocarditis; acute and subacute bacterial endocarditis 421.1 Acute and subacute endocarditis; acute and subacute infective endocarditis in diseases classified elsewhere 421.9 Acute and subacute endocarditis; acute endocarditis, unspecified 422.0 Acute myocarditis; acute myocarditis in diseases classified elsewhere 422.90 Acute myocarditis; acute myocarditis, unspecified 422.91 Acute myocarditis; idiopathic myocarditis 422.92 Acute myocarditis; septic myocarditis 422.93 Acute myocarditis; toxic myocarditis 422.99 Acute myocarditis; toxic myocarditis 423.0 Other diseases of pericardium; hemopericardium

Cardiovascular Magnetic Resonance (CMR) Page 8 of 16 423.1 Other diseases of pericardium; adhesive pericarditis 423.2 Other diseases of pericardium; constrictive pericarditis 423.3 Other diseases of pericardium; cardiac tamponade 423.8 Other diseases of pericardium; other specified diseases of pericardium 423.9 Other diseases of pericardium; unspecified disease of pericardium 424.0 Other diseases of endocardium; mitral valve disorders 424.1 Other diseases of endocardium; aortic valve disorders 424.2 Other diseases of endocardium; tricuspid valve disorders, specified as non-rheumatic 424.3 Other diseases of endocardium; pulmonary valve disorders 424.90 Other diseases of endocardium; endocarditis, valve unspecified, unspecified cause 424.91 Other diseases of endocardium; endocarditis in diseases classified elsewhere 424.99 Other diseases of endocardium; other 441.00 Aortic aneurysm and dissection; Dissection of aorta; unspecified site 441.01 Aortic aneurysm and dissection; Dissection of aorta; thoracic 441.02 Aortic aneurysm and dissection; Dissection of aorta; abdominal 441.03 Aortic aneurysm and dissection; Dissection of aorta; thoracoabdominal 441.1 Aortic aneurysm and dissection; Thoracic aneurysm, ruptured 441.2 Aortic aneurysm and dissection; Thoracic aneurysm without mention of rupture 441.3 Aortic aneurysm and dissection; Abdominal aneurysm, ruptured 441.4 Aortic aneurysm and dissection; Abdominal aneurysm without mention of rupture 441.5 Aortic aneurysm and dissection; Aortic aneurysm of unspecified site, ruptured 441.6 Aortic aneurysm and dissection; Thoracoabdominal aneurysm, ruptured 441.7 Aortic aneurysm and dissection; Thoracoabdominal aneurysm, without mention of rupture 441.9 Aortic aneurysm and dissection; Aortic aneurysm of unspecified site without mention of rupture 444.01 Arterial embolism and thrombosis; of the abdominal aorta; saddle embolus of abdominal aorta 444.09 Arterial embolism and thrombosis; of the abdominal aorta; other arterial embolism and thrombosis of abdominal aorta 444.1 Arterial embolism and thrombosis; of thoracic aorta 452 Portal vein thrombosis 453.0 Other venous embolism and thrombosis; Budd-Chiari syndrome 453.2 Other venous embolism and thrombosis; of vena cava 511.0 Pleurisy; without mention of effusion or current tuberculosis 511.1 Pleurisy; with effusion, with mention of a bacterial cause other than tuberculosis 511.8 Pleurisy; other specified forms of effusion, except tuberculous 572.1 Liver abscess and sequelae of chronic liver disease; portal pyemia 745.0 Bulbus cordis anomalies and anomalies of cardiac septal closure; common truncus 745.10 Transposition of great vessels; complete transposition of great vessels 745.11 Transposition of great vessels; double outlet right ventricle 745.12 Transposition of great vessels; corrected transposition of great vessels 745.19 Transposition of great vessels; other 745.2 Bulbus cordis anomalies and anomalies of cardiac septal closure; Tetralogy of Fallot 745.3 Bulbus cordis anomalies and anomalies of cardiac septal closure; common ventricle 745.4 Bulbus cordis anomalies and anomalies of cardiac septal closure; ventricular septal defect

Cardiovascular Magnetic Resonance (CMR) Page 9 of 16 745.5 Bulbus cordis anomalies and anomalies of cardiac septal closure; ostium secundum type atrial septal defect 745.60 Endocardial cushion defects; unspecified type 745.61 Endocardial cushion defects; ostium primum defect 745.69 Endocardial cushion defects; other 745.7 Bulbus cordis anomalies and anomalies of cardiac septal closure; cor biloculare 745.8 Bulbus cordis anomalies and anomalies of cardiac septal closure; other 745.9 Bulbus cordis anomalies and anomalies of cardiac septal closure; unspecified defect of septal closure 746.00 Anomalies of pulmonary valve; pulmonary valve anomaly, unspecified 746.01 Anomalies of pulmonary valve; atresia, congenital 746.02 Anomalies of pulmonary valve; stenosis, congenital 746.09 Anomalies of pulmonary valve; other 746.1 Other congenital anomalies of heart; tricuspid atresia and stenosis, congenital 746.2 Other congenital anomalies of heart; Ebstein's anomaly 746.3 Other congenital anomalies of heart; congenital stenosis of aortic valve 746.4 Other congenital anomalies of heart; congenital insufficiency of aortic valve 746.5 Other congenital anomalies of heart; congenital mitral stenosis 746.6 Other congenital anomalies of heart; congenital mitral insufficiency 746.7 Other congenital anomalies of heart; hypoplastic left heart syndrome 746.81 Other specified anomalies of heart; subaortic stenosis 746.82 Other specified anomalies of heart; cor triatriatum 746.83 Other specified anomalies of heart; infundibular pulmonic stenosis 746.84 Other specified anomalies of heart; obstructive anomalies of heart, not elsewhere classified 746.85 Other specified anomalies of heart; coronary artery anomaly 746.86 Other specified anomalies of heart; congenital heart block 746.87 Other specified anomalies of heart; malposition of heart and cardiac apex 746.89 Other specified anomalies of heart; other 746.9 Unspecified anomaly of heart 747.0 Other congenital anomalies of circulatory system; patent ductus arteriosus 747.10 Coarctation of aorta; (preductal) (postductal) 747.11 Coarctation of aorta; interruption of aortic arch 747.20 Other anomalies of aorta; unspecified 747.21 Other anomalies of aorta; anomalies of aortic arch 747.22 Other anomalies of aorta; atresia and stenosis or aorta 747.29 Other anomalies of aorta; other 747.31 Anomalies of pulmonary artery; pulmonary artery coarctation and atresia 747.32 Anomalies of pulmonary artery; pulmonary arteriovenous malformation 747.39 Anomalies of pulmonary artery; other anomalies of pulmonary artery and pulmonary circulation 747.40 Anomalies of great veins; unspecified 747.41 Anomalies of great veins; total anomalous pulmonary venous connection 747.42 Anomalies of great veins; partial anomalous pulmonary venous connection 747.49 Anomalies of great veins; other anomalies of great veins 759.82 Other specified anomalies; Marfan syndrome 786.6 Chest pain; swelling, mass, or lump in chest

Cardiovascular Magnetic Resonance (CMR) Page 10 of 16 793.2 Nonspecific abnormal findings on radiological and other examination of body structure; other intrathoracic organs 794.30 Cardiovascular; abnormal function study, unspecified 794.31 Cardiovascular; abnormal electrocardiogram [ECG] [EKG] V45.82 Other postprocedural status; percutaneous transluminal coronary angioplasty status ICD-10 Diagnoses A18.84 Tuberculosis of heart A52.00 Cardiovascular syphilis, unspecified A52.01 Syphilitic aneurysm of aorta A52.02 Syphilitic aortitis A52.03 Syphilitic endocarditis A52.04 Syphilitic cerebral arteritis A52.06 Other syphilitic heart involvement A52.09 Other cardiovascular syphilis C34.01 Malignant neoplasm of right main bronchus C34.02 Malignant neoplasm of left main bronchus C34.11 Malignant neoplasm of upper lobe, right bronchus or lung C34.12 Malignant neoplasm of upper lobe, left bronchus or lung C34.2 Malignant neoplasm of middle lobe, bronchus or lung C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.32 Malignant neoplasm of lower lobe, left bronchus or lung C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung C38.0 Malignant neoplasm of heart C38.1 Malignant neoplasm of anterior mediastinum C38.2 Malignant neoplasm of posterior mediastinum C38.3 Malignant neoplasm of mediastinum, part unspecified C38.4 Malignant neoplasm of pleura C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura C45.0 Mesothelioma of pleura C45.2 Mesothelioma of pericardium C47.3 Malignant neoplasm of peripheral nerves of thorax C49.3 Malignant neoplasm of connective and soft tissue of thorax C78.01 Secondary malignant neoplasm of right lung C78.02 Secondary malignant neoplasm of left lung C78.1 Secondary malignant neoplasm of mediastinum C78.2 Secondary malignant neoplasm of pleura D14.31 Benign neoplasm of right bronchus and lung D14.32 Benign neoplasm of left bronchus and lung D15.0 Benign neoplasm of thymus D15.1 Benign neoplasm of heart D15.2 Benign neoplasm of mediastinum D17.4 Benign lipomatous neoplasm of intrathoracic organs D19.0 Benign neoplasm of mesothelial tissue of pleura D21.3 Benign neoplasm of connective and other soft tissue of thorax D38.1 Neoplasm of uncertain behavior of trachea, bronchus and lung

Cardiovascular Magnetic Resonance (CMR) Page 11 of 16 D38.2 Neoplasm of uncertain behavior of pleura D38.3 Neoplasm of uncertain behavior of mediastinum D38.4 Neoplasm of uncertain behavior of thymus I00 Rheumatic fever without heart involvement I01.0 Acute rheumatic pericarditis I01.1 Acute rheumatic endocarditis I01.2 Acute rheumatic myocarditis I01.8 Other acute rheumatic heart disease I02.0 Rheumatic chorea with heart involvement I02.9 Rheumatic chorea without heart involvement I05.0 Rheumatic mitral stenosis I05.1 Rheumatic mitral insufficiency I05.2 Rheumatic mitral stenosis with insufficiency I05.8 Other rheumatic mitral valve diseases I06.0 Rheumatic aortic stenosis I06.1 Rheumatic aortic insufficiency I06.2 Rheumatic aortic stenosis with insufficiency I06.8 Other rheumatic aortic valve diseases I07.0 Rheumatic tricuspid stenosis I07.1 Rheumatic tricuspid insufficiency I07.2 Rheumatic tricuspid stenosis and insufficiency I07.8 Other rheumatic tricuspid valve diseases I08.0 Rheumatic disorders of both mitral and aortic valves I08.1 Rheumatic disorders of both mitral and tricuspid valves I08.2 Rheumatic disorders of both aortic and tricuspid valves I08.3 Combined rheumatic disorders of mitral, aortic and tricuspid valves I08.8 Other rheumatic multiple valve diseases I09.0 Rheumatic myocarditis I09.1 Rheumatic diseases of endocardium, valve unspecified I09.2 Chronic rheumatic pericarditis I09.81 Rheumatic heart failure I09.89 Other specified rheumatic heart diseases I20.0 Unstable angina I24.0 Acute coronary thrombosis not resulting in myocardial infarction I24.1 Dressler's syndrome I24.8 Other forms of acute ischemic heart disease I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris

Cardiovascular Magnetic Resonance (CMR) Page 12 of 16 I26.01 Septic pulmonary embolism with acute cor pulmonale I26.09 Other pulmonary embolism with acute cor pulmonale I26.90 Septic pulmonary embolism without acute cor pulmonale I26.99 Other pulmonary embolism without acute cor pulmonale I28.0 Arteriovenous fistula of pulmonary vessels I28.1 Aneurysm of pulmonary artery I28.8 Other diseases of pulmonary vessels I30.0 Acute nonspecific idiopathic pericarditis I30.1 Infective pericarditis I30.8 Other forms of acute pericarditis I31.0 Chronic adhesive pericarditis I31.1 Chronic constrictive pericarditis I31.2 Hemopericardium, not elsewhere classified I31.3 Pericardial effusion (noninflammatory) I31.4 Cardiac tamponade I31.8 Other specified diseases of pericardium I32 Pericarditis in diseases classified elsewhere I33.0 Acute and subacute infective endocarditis I33.9 Acute and subacute endocarditis, unspecified I34.0 Nonrheumatic mitral (valve) insufficiency I34.1 Nonrheumatic mitral (valve) prolapse I34.2 Nonrheumatic mitral (valve) stenosis I34.8 Other nonrheumatic mitral valve disorders I35.0 Nonrheumatic aortic (valve) stenosis I35.1 Nonrheumatic aortic (valve) insufficiency I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency I35.8 Other nonrheumatic aortic valve disorders I36.0 Nonrheumatic tricuspid (valve) stenosis I36.1 Nonrheumatic tricuspid (valve) insufficiency I36.2 Nonrheumatic tricuspid (valve) stenosis with insufficiency I36.8 Other nonrheumatic tricuspid valve disorders I37.0 Nonrheumatic pulmonary valve stenosis I37.1 Nonrheumatic pulmonary valve insufficiency I37.2 Nonrheumatic pulmonary valve stenosis with insufficiency I37.8 Other nonrheumatic pulmonary valve disorders I38 Endocarditis, valve unspecified I39 Endocarditis and heart valve disorders in diseases classified elsewhere I40.0 Infective myocarditis I40.1 Isolated myocarditis I40.8 Other acute myocarditis I41 Myocarditis in diseases classified elsewhere I71.01 Dissection of thoracic aorta I71.02 Dissection of abdominal aorta I71.03 Dissection of thoracoabdominal aorta I71.1 Thoracic aortic aneurysm, ruptured I71.2 Thoracic aortic aneurysm, without rupture I71.3 Abdominal aortic aneurysm, ruptured I71.4 Abdominal aortic aneurysm, without rupture

Cardiovascular Magnetic Resonance (CMR) Page 13 of 16 I71.5 Thoracoabdominal aortic aneurysm, ruptured I71.6 Thoracoabdominal aortic aneurysm, without rupture I71.9 Aortic aneurysm of unspecified site, without rupture I74.11 Embolism and thrombosis of thoracic aorta I79.0 Aneurysm of aorta in diseases classified elsewhere I81 Portal vein thrombosis I82.0 Budd-Chiari syndrome I82.220 Acute embolism and thrombosis of inferior vena cava I82.221 Chronic embolism and thrombosis of inferior vena cava J86.9 Pyothorax without fistula J90 Pleural effusion, not elsewhere classified J92.0 Pleural plaque with presence of asbestos J92.9 Pleural plaque without asbestos J94.1 Fibrothorax J94.2 Hemothorax J94.8 Other specified pleural conditions K75.1 Phlebitis of portal vein M32.11 Endocarditis in systemic lupus erythematosus M32.12 Pericarditis in systemic lupus erythematosus Q20.0 Common arterial trunk Q20.1 Double outlet right ventricle Q20.2 Double outlet left ventricle Q20.3 Discordant ventriculoarterial connection Q20.4 Double inlet ventricle Q20.5 Discordant atrioventricular connection Q20.6 Isomerism of atrial appendages Q20.8 Other congenital malformations of cardiac chambers and connections Q21.0 Ventricular septal defect Q21.1 Atrial septal defect Q21.2 Atrioventricular septal defect Q21.3 Tetralogy of Fallot Q21.4 Aortopulmonary septal defect Q21.8 Other congenital malformations of cardiac septa Q22.0 Pulmonary valve atresia Q22.1 Congenital pulmonary valve stenosis Q22.2 Congenital pulmonary valve insufficiency Q22.3 Other congenital malformations of pulmonary valve Q22.4 Congenital tricuspid stenosis Q22.5 Ebstein's anomaly Q22.6 Hypoplastic right heart syndrome Q22.8 Other congenital malformations of tricuspid valve Q23.0 Congenital stenosis of aortic valve Q23.1 Congenital insufficiency of aortic valve Q23.2 Congenital mitral stenosis Q23.3 Congenital mitral insufficiency Q23.4 Hypoplastic left heart syndrome Q23.8 Other congenital malformations of aortic and mitral valves Q24.0 Dextrocardia

Cardiovascular Magnetic Resonance (CMR) Page 14 of 16 Q24.1 Levocardia Q24.2 Cor triatriatum Q24.3 Pulmonary infundibular stenosis Q24.4 Congenital subaortic stenosis Q24.5 Malformation of coronary vessels Q24.6 Congenital heart block Q24.8 Other specified congenital malformations of heart Q25.0 Patent ductus arteriosus Q25.1 Coarctation of aorta Q25.21 Interruption of aortic arch Q25.29 Other atresia of aorta Q25.3 Supravalvular aortic stenosis Q25.40 Congenital malformation of aorta unspecified Q25.41 Absence and aplasia of aorta Q25.42 Hypoplasia of aorta Q25.43 Congenital aneurysm of aorta Q25.44 Congenital dilation of aorta Q25.45 Double aortic arch Q25.46 Tortuous aortic arch Q25.47 Right aortic arch Q25.48 Anomalous origin of subclavian artery Q25.49 Other congenital malformations of aorta Q25.8 Other congenital malformations of other great arteries Q26.0 Congenital stenosis of vena cava Q26.1 Persistent left superior vena cava Q26.2 Total anomalous pulmonary venous connection Q26.3 Partial anomalous pulmonary venous connection Q26.4 Anomalous pulmonary venous connection, unspecified Q26.8 Other congenital malformations of great veins Q87.40 Marfan's syndrome, unspecified Q87.410 Marfan's syndrome with aortic dilation Q87.418 Marfan's syndrome with other cardiovascular manifestations Q87.42 Marfan's syndrome with ocular manifestations Q87.43 Marfan's syndrome with skeletal manifestation R09.1 Pleurisy R22.2 Localized swelling, mass and lump, trunk R93.1 Abnormal findings on diagnostic imaging of heart and coronary circulation R93.8 Abnormal findings on diagnostic imaging of other specified body structures R94.30 Abnormal result of cardiovascular function study, unspecified R94.31 Abnormal electrocardiogram [ECG] [EKG] T80.0xxA Air embolism following infusion, transfusion and therapeutic injection, initial encounter T81.718A Complication of other artery following a procedure, not elsewhere classified, initial encounter T81.72xA Complication of vein following a procedure, not elsewhere classified, initial encounter T82.817A Embolism of cardiac prosthetic devices, implants and grafts, initial encounter T82.818A Embolism of vascular prosthetic devices, implants and grafts, initial encounter

Cardiovascular Magnetic Resonance (CMR) Page 15 of 16 Z95.5 Presence of coronary angioplasty implant and graft Z98.61 Coronary angioplasty status REVISIONS Effective 07-01-2006 Effective 11-01-2007 The Medical Director added to the Policy section "of the coronary arteries", removed "as a screening test" from CV MRI and removed "for diagnosis and screening" from CV MRA for clarification. Policy section was revised to combine information from item F. to B11. Item F. was deleted and stated, "Pulmonary venous assessment in association with atrial fibrillation dysfunctions prior to electro physiology ablation." Item B11 was modified from, "Assessment of pulmonary veins" to its current verbiage. The following paragraph was deleted to remove the definition of class I classification of cardiovascular conditions: "CMR is medically necessary for indications that include an expert Consensus panel's class I classification of cardiovascular conditions. A class I classification is defined as: provides clinically relevant information and is usually appropriate; may be used as first line imaging technique; usually supported by substantial literature." Under "Experimental/investigational indications:" added to number 2, "for diagnosis and screening". Under "Subject to review for medical necessity:" added to number 1, " indications that are not listed above." and deleted, " all indications. Medical records should clearly document medical necessity." A Diagnosis section was added to the policy to reflect all the appropriate diagnoses eligible for this procedure. Previously no diagnoses codes were reflected in the policy. Revision section was added. References were updated. 01-01-2010 In Coding section: Removed CPT Codes: 75552, 75553, 75554, 75555 (effective January 1, 2008) Removed CPT Codes: 75558, 75560, 75562, 75564 (effective January 2, 2010) Added CPT Codes: 75557, 75558, 75559, 75560, 75561, 75562, 75563, 75564 (effective January 1, 2008) Added CPT Code: 75565 (effective January 1, 2010) Removed Diagnosis Code: 794.30 Added Diagnosis Codes: 411.0-410.9, 415.12, 423.3, 794.31 02-15-2013 Added Medical Policy and Coding Disclaimers. In the Policy section: Formatted medical policy language. In Item B, #2, added "of coronary artery disease" to read "Coronary MRA for diagnosis and screening of coronary artery disease" In Coding section: Nomenclature reviewed and updated 12-11-2013 Policy reviewed. In Coding section: Added ICD-10 Diagnosis codes (Effective October 1, 2014) Updated Reference section. 04-15-2014 In Policy section: In Item B 2 removed "diagnosis and" to read, "Coronary MRA for screening of coronary artery disease." 07-15-2014 Description section reviewed.

Cardiovascular Magnetic Resonance (CMR) Page 16 of 16 In Policy section: In Item A b 5, removed "apical" to read, "Hypertrophic cardiomyopathy" In Item A 4 added a new indication of, "f. Restrictive cardiomyopathy" In Item A 5 b added "or stenosis" to read "Quantification of regurgitation or stenosis" Coding section reviewed References updated 06-10-2015 Policy reviewed; no changes made. 06-08-2016 Policy reviewed; no changes made. 10-01-2016 In Coding section: Added ICD-10 codes effective 10-01-2016: Q25.21, Q25.29, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49 Termed ICD-10 codes effective 09-30-2016: Q25.2, Q25.4 05-10-2017 Policy reviewed; no changes made. REFERENCES 1. Pennell, D.J., Sachem, U.P., Higgins, C.B., et al. (2004). Clinical Indications for Cardiovascular Magnetic Resonance: Consensus Panel Report. Journal of Cardiovascular Magnetic Resonance 6, No.4: 727-765. 2. Blue Cross and Blue Shield of Kansas Cardiology Liaison Committee, May 2, 2007; May 2013; May 2014; May 2015. 3. Blue Cross and Blue Shield of Kansas Medical Advisory Committee (MAC), August 2, 2007.