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Authorization Criteria: Cardiac Magnetic Resonance Imaging of the Coronary Arteries

Revised: 03-04-2011

MHCP will cover Cardiac Magnetic Resonance Imaging (MRI) for the indications listed below. Scans must be performed using scanners with a magnetic field intensity of 1.5 Tesla units or greater and a slew rate of at least 70mT/m/sec. Also, a localized multichannel radiofrequency surface coil and electrocardiographic gating are required.

Indication when will not cover:
For the diagnosis and evaluation of coronary artery disease.

Indication when will cover:
For evaluative and diagnostic procedure when medically necessary. Indications supporting medical necessity include:

  • 1. Congenital Heart Disease – assessment of complex congenital heart disease including anomalies of coronary circulation, great vessels, and cardiac chambers and valves.
  • 2. Cardiomyopathy – evaluation of arrhythmogenic right ventricular dysplasia.
  • 3. Intra-cardiac and para-cardiac masses
  • 4. Post-myocardial infarct – evaluation of myocardial scar tissue viability prior to surgical revascularization.

  • MHCP Provider Call Center
    (651) 431-2700 or 1-800-366-5411; TDD: 7-1-1

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