Magnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI (CPB 0520, reviewed 2025-08-13)

IMMEDIATELY: (1) Billing team must update claim adjudication system to require medical necessity documentation for all cardiac MRI claims using CPT 75557, 75559, 75561, 75563, 75565. (2) Configure system to DENY claims for experimental codes 0899T, 0900T and deny Q0138 (ferumoxytol) unless documentation explicitly supports a covered indication. (3) Create an internal approval checklist requiring providers to document which covered indication from the policy (e.g., 'thoracic aortic disease,' 'congenital heart disease,' 'after echocardiogram inconclusive') justifies the cardiac MRI before claim submission. (4) Flag all claims for whole-heart coronary MRA or 4D flow cMRI for manual review and denial, as these remain experimental. (5) For cardiac MRI related to coronary artery disease, verify that claims reference either myocardial perfusion deficits, myocardial infarction assessment, OR appropriately document that SPECT imaging was unavailable/contraindicated. (6) Implement dual-imaging denial rule: systematically deny payment for cardiac MRI when performed within 90 days of CT, ultrasound, or nuclear imaging of the same anatomical region unless provider documentation explains specific clinical value of additional imaging. Failure to implement these controls will result in claim denials and potential compliance issues with Aetna's medical necessity standards.