CurrentColorado Rocky Mountain Health PlansPolicy CSRAD015OH.E

Pediatric Abdomen Imaging Guidelines (Ohio)

Clinical guidelines governing advanced imaging of the pediatric abdomen for members in Ohio; defines application, documentation expectations, and condition-specific sections for medical necessity review.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPediatric Abdomen Imaging Guidelines (Ohio)

Policy CodePolicy CSRAD015OH.E

Change TypeNo material changes

Effective DateFeb 3, 2026

Next Review DateN/A

Key ActionObtain and document a recent clinical evaluation (history, exam, labs, prior imaging) before ordering advanced pediatric abdominal imaging; use ultrasound as first-line when appropriate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

V1.0.2026guideline version

Ohioapplicable state

>=27PEDAB sections

US first-lineUS first-line

<30GFR threshold

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria — Pediatric Abdomen Imaging

Modality selection and contrast criteria

Covered when imaging choice meets clinical presentation and documentation requirements and is expected to affect management.

General prerequisites: Clinical presentation-driven request; adequate clinical evaluation documented (detailed history, physical exam, pertinent labs, and prior imaging where applicable); advanced imaging expected to affect management decisions

See Documentation; meaningful telehealth/phone/email contact can satisfy clinical evaluation when applicable

Modality-specific appropriateness: Select the modality appropriate to the clinical question: Ultrasound for initial/bedside soft-tissue and abdominal assessment; CT for trauma, urgent evaluation of abdominal/pelvic viscera, and when radiation trade-offs are acceptable; MRI for soft-tissue characterization, CNS/spine, and when avoiding ionizing radiation is preferable

Contrast level determined by condition-specific guidance

Contrast and renal function: Avoid gadolinium or iodinated contrast in patients with GFR <30 mL/min unless benefits outweigh risks; when CT with contrast is indicated but contraindicated (renal insufficiency or contrast allergy), CT without contrast is medically necessaryGFR <30 mL/min

CT and MRI contrast have similar renal-failure risk profiles; breastfeeding pump-and-discard 12–24 hrs may be considered after iodinated CT contrast

Indications for 3D rendering

CPT 76376 or 76377 can be considered in the following clinical scenarios:

3D rendering indications: Pre-operative 3D rendering (CPT 76376/76377) for complex anatomic evaluation such as congenital skull abnormalities in newborns/infants/toddlers, complex fractures/dislocations (spine, pelvis, intra-articular), complex facial fractures, planning for complex surgical cases, cerebral angiography, and select pelvis/abdomen conditions (e.g., CT urogram, MRCP) when conventional imaging is insufficient.

Concurrent physician supervision/participation should be documented per guidance.

Indications for unlisted CT/MR procedures

CPT 76497 or 76498 (Unlisted CT or MR) is medically necessary in the following scenarios:

Unlisted procedure indications: Use unlisted CT (76497) or MR (76498) when no anatomic site–specific CPT exists or when imaging is performed for navigation/planning that requires thinner cuts or nonstandard positional acquisition (examples: neurosurgical Stealth/BrainLab planning, custom joint arthroplasty planning, navigational bronchoscopy), and when a Category III code is unavailable.

Provide clinical rationale and report a Category III code if available.

Billing and usage criteria for imaging guidance codes

Guidance procedure billing rules and limitations:

Guidance code billing constraints: Imaging guidance codes (CT/MR/US/fluoroscopy guidance) include the imaging necessary to guide percutaneous needle or catheter procedures; it is inappropriate to routinely bill a separate diagnostic imaging code in conjunction with a guidance code. Only percutaneous procedures should be billed with guidance codes. CPT 77021 is not appropriate for breast biopsy; CPT 77011 (stereotactic localization) is a technical service unless a diagnostic CT requiring interpretation is performed; do not report CPT 70486 and CPT 77011 together for the same session. Only one unit of a guidance code should be reported per encounter (date of service).

Documentation should support why both guidance and any additional imaging are necessary.

Unlisted CT/MR (76497/76498) Indications

Covered when ANY of the following are met

Unlisted CT/MR use cases: Report CPT 76497 or 76498 when an anatomic site–specific code is not available, or for navigation/planning (e.g., neurosurgical Stealth/BrainLab imaging), custom arthroplasty planning, or when different acquisition parameters (thinner cuts or alternate positioning) are required compared with the completed diagnostic study.

Category III code must be used instead of unlisted if available; include clinical rationale.

Limited/Follow-up CT (76380)

Covered with constraints

Limited CT (76380): Use CPT 76380 to report a limited or follow-up CT when the work of a full diagnostic CT code is not performed (examples: limited sinus CT, limited slices through known pulmonary nodule, limited slices for non-healing fracture). CPT 76380 is not medically necessary for treatment planning and should not be used to cover additional slices when a diagnostic CT code is appropriate.

No specific slice/sequence counts defined; clinical justification required.

Whole-body and PET/MRI Coverage

Coverage stance for whole-body imaging

Whole-body CT (LifeScan) for screening of asymptomatic individuals is not a covered benefit.

Exception: whole-body low-dose skeletal CT supported for Multiple Myeloma staging per oncology guidelines.

Whole-body MRI is generally not supported due to lack of standardization and evidence of improved outcomes; exceptions include select cancer predisposition syndromes and certain autoimmune conditions (e.g., chronic recurrent multifocal osteomyelitis).

WBMRI currently reportable only using CPT 76498.

PET/MRI may be medically necessary when condition-specific PET/MRI criteria are met OR when PET/CT criteria are met and PET/CT is unavailable and the provider requests PET/MRI; when approved report PET whole-body (78813) plus MRI unlisted (76498).

Diagnostic MRI codes may be necessary concurrently when appropriate.

General prerequisites for advanced imaging

Covered when ALL of the following are met

Pertinent clinical evaluation: A pertinent clinical evaluation since onset or change in symptoms (detailed history, physical exam, appropriate laboratory studies, and prior basic imaging such as radiography or ultrasound) is performed prior to advanced imaging unless the request is for guideline-supported scheduled surveillance imaging.

Meaningful telehealth/phone/email contact can satisfy clinical evaluation when applicable

Impact on management: Advanced imaging must be expected to answer a specific clinical question that will affect individual management; imaging is not indicated if results will not change management.

Conservative therapy should typically be continued prior to advanced imaging in improving individuals

Ultrasound first-line: Ultrasound should be the initial imaging study of choice in most children with abdominal conditions and should be performed prior to advanced imaging unless red flags or guideline-specific exceptions apply.

Ultrasound helps determine proper modality, sequences, and contrast for subsequent advanced imaging if needed

Red flags prompting additional investigation (may bypass initial ultrasound)

Additional investigation including advanced imaging is indicated when the child with abdominal pain has ANY of the following red-flag signs or symptoms

Red flag list: Pain that wakes the child from sleep; unexplained fever >100.4°F; history of malignancy with propensity to metastasize to the abdomen; dysphagia; GI bleeding; significant vomiting; abnormal WBC (elevated or ANC <1000); guarding, rebound or other peritoneal signs; severe chronic or nocturnal diarrhea in a toilet-trained child; failure to thrive, involuntary weight loss, or delayed growth/puberty; family history of IBD/familial polyposis/celiac disease/peptic ulcer disease; abdominal mass, hepatomegaly, or splenomegaly; jaundice; perianal disease; suspected/confirmed COVID-19 with concern for MIS-C; failure to respond to 4 weeks of provider-directed conservative care (within 60 days)ANY

Presence of any red flag precludes adjudication by other lower-acuity criteria and directs toward higher-acuity imaging per condition-specific guidance.

Generalized abdominal pain imaging pathway

Initial imaging: Ultrasound Abdomen (CPT 76700 or 76705) is medically necessary as the initial imaging for children with no red flags, normal physical exam, and normal preliminary laboratory studies (examples: CBC, electrolytes, lipase, amylase, urinalysis, ESR, CRP, LFTs, stool tests when applicable).

GI specialist consultation may assist in determining need for advanced imaging

When CT is necessary: CT Abdomen (CPT 74160) with contrast or CT Abdomen and Pelvis (CPT 74177) with contrast is medically necessary if any red flag signs or symptoms are present.ANY

Children with pain localized to a quadrant should follow the relevant condition-specific guideline

Generalized Abdominal Pain — initial imaging

Covered when ALL of the following are met

Initial ultrasound for generalized abdominal pain: Ultrasound Abdomen (CPT 76700 or 76705) is medically necessary as the initial imaging for children with no red flags, normal physical exam, and normal laboratory studies (preliminary labs may include CBC, electrolytes, lipase, amylase, urinalysis, ESR, CRP, LFTs, and stool testing if diarrhea).

GI specialist evaluation or consultation helpful to determine need for advanced imaging

Generalized Abdominal Pain — advanced imaging with red flags

Covered when ANY of the following are present

CT for red flags: CT Abdomen (CPT 74160) with contrast or CT Abdomen and Pelvis (CPT 74177) with contrast is medically necessary when any red flag signs or symptoms (per PEDAB-1.0) are present.

Red flag presence supersedes lower-acuity pathways.

Right Lower Quadrant Pain / Suspected Appendicitis

Covered when ALL of the following conditions are met (staged logic applies)

Ultrasound initial: Ultrasound (CPT 76700 or 76705) is the medically necessary initial examination for suspected appendicitis. If ultrasound is diagnostic (positive or clearly negative for uncomplicated appendicitis), no further imaging is necessary.

If appendix not visualized and WBC is not elevated, further imaging is generally not required; referring physician determines final need.

Indications for CT/MRI: CT Abdomen and Pelvis with contrast (CPT 74177) or MRI Abdomen and Pelvis (CPT 74181/74183 and pelvic MRI CPT 72195/72197) is medically necessary for individuals who are overweight (BMI ≥85th percentile for age), when local ultrasound expertise is insufficient, when ultrasound is inconclusive, or when there is clinical suspicion of complication (e.g., abscess, obstruction).BMI ≥85th percentile

Presence of red flags still directs to higher-acuity imaging.

Flank Pain / Renal Stone

Covered when ALL of the following are met (staged approach)

Ultrasound initial for flank pain: Ultrasound (CPT 76770 or CPT 76775) is the medically necessary initial study in children with flank pain or suspected renal stone.

CT if ultrasound inconclusive: CT Abdomen and Pelvis without contrast (CPT 74176) is medically necessary if ultrasound is inconclusive. MRI Abdomen and Pelvis (CPT 74183 and CPT 72197) without and with contrast is medically necessary to avoid radiation when CT is inconclusive or when limiting radiation exposure is a priority due to frequent prior CTs.

Upper and Lower Urinary Tract Infection Imaging

Covered when ALL of the following are met for first-time or complicated UTI

Ultrasound initial for UTI: Ultrasound evaluation (CPT 76770 or CPT 76775) is the medically necessary initial imaging for all children with first-time upper urinary tract infection to assess for hydronephrosis, pyelonephritis, or congenital renal anomaly.

VCUG and follow-up studies: If hydronephrosis is present, further evaluation with fluoroscopic VCUG or radiopharmaceutical voiding cystogram (CPT 78740) or Contrast-Enhanced Voiding Urosonography (CeVUS) is medically necessary to evaluate for vesicoureteral reflux; fluoroscopic VCUG is typically used in boys to evaluate the urethra.

Nuclear studies for recurrent/atypical UTI: Diuretic renography (CPT 78707/78708/78709) is medically necessary to distinguish obstructive from non-obstructive dilation and quantify function; DMSA cortical scintigraphy (CPT 78700/78701/78803) is medically necessary for atypical or recurrent febrile UTIs and for detection of cortical scarring at least 6 months after infection.

MR urography is medically necessary for complex anatomy or ectopic distal ureteral insertion; MRU may require sedation in young children.

Pediatric Acute Gastroenteritis — Advanced Imaging

Covered when specific conditions are met:

Gastroenteritis CT indication: CT Abdomen and Pelvis with contrast (CPT 74177) is medically necessary if abdominal red flag symptoms are present as listed in the General Guidelines (PEDAB-1.0).

Advanced imaging otherwise not medically necessary unless alternative diagnosis suspected.

Hematuria — Imaging Indications

Imaging coverage depends on clinical presentation:

Asymptomatic gross or microscopic with proteinuria: Ultrasound kidneys (CPT 76770/76775) and bladder (CPT 76856/76857) are medically necessary for asymptomatic gross hematuria or microscopic hematuria with proteinuria.

Imaging is not medically necessary for asymptomatic microscopic hematuria without proteinuria.

Painful hematuria: For painful hematuria without recent trauma, any of CT Abdomen and Pelvis without contrast (CPT 74176), ultrasound kidneys, or ultrasound bladder are medically necessary.

Hematuria with recent trauma: For hematuria with recent trauma, CT Abdomen and Pelvis with contrast (CPT 74177) is medically necessary; CT cystography (CPT 72193) is medically necessary if gross hematuria with suspected pelvic fracture or bladder injury. 3D reconstruction (CPT 76376/76377) may be medically necessary for surgical planning if requested.

Right Upper Quadrant Pain — Imaging Pathway

Covered when consistent with diagnostic pathway:

Initial diagnosis of suspected cholecystitis or gallstone disease: Ultrasound abdomen (CPT 76700) and/or hepatobiliary scintigraphy (HIDA CPT 78226/78227) are medically necessary for initial diagnosis of suspected acute or acalculous cholecystitis and suspected gallstones or bile duct obstruction.

Ultrasound not required prior to HIDA.

Equivocal ultrasound or HIDA: MRI Abdomen with and without contrast (CPT 74183) or CT Abdomen with contrast (CPT 74160) is medically necessary when ultrasound or nuclear medicine is equivocal.

If ultrasound shows only gallstones and no fever, MRI/CT/HIDA may be used to exclude other pain sources.

Inflammatory Bowel Disease (IBD) — Enterography and Pelvic MRI

Covered indications for enterography and pelvic MRI in children with suspected or established IBD:

Preferred modality: Enterography (MR Enterography CPT 74183 preferred; CT Enterography CPT 74177 acceptable) is the medically necessary advanced imaging for evaluation of IBD in children; MR Enterography is preferred to avoid radiation.

Suspected Crohn disease indications: MR Enterography, CT Enterography, or MRI Abdomen and Pelvis without and with contrast is medically necessary to detect severity/distribution of inflammatory changes, identify complications (fistula, abscess), or when chronic abdominal pain with diarrhea raises concern for IBD given family history, endoscopic findings, or elevated inflammatory markers (fecal lactoferrin ≥4.0 ug/g, CRP >0.5 mg/dL, fecal calprotectin ≥50 ug/g).

May be medically necessary prior to endoscopy if requested by endoscopist.

Established IBD monitoring: MR Enterography, CT Enterography, or MRI Abdomen and Pelvis without and with contrast is medically necessary for annual monitoring, when treatment changes are considered, for post-operative recurrence monitoring, or for new/worsening symptoms or suspected complications.

CT Abdomen and Pelvis with contrast (CPT 74177) may be used if requested instead of enterography for new/worsening symptoms or suspected complications.

Abdominal Sepsis (Suspected Abscess)

Abdominal sepsis / suspected abscess

Abdominal sepsis imaging: Imaging indications for abdominal sepsis or suspected intra-abdominal abscess in pediatric individuals follow adult abdominal sepsis guidance (AB-3); select CT, MRI, or ultrasound based on clinical context and timeliness needs.

Refer to adult Abdomen Imaging Guidelines (AB-3) for modality selection.

Postoperative Pain (≤60 days)

Postoperative abdominal pain within 60 days

Studies medically necessary for suspected postoperative complications: CT Abdomen and Pelvis with contrast (CPT 74177); Ultrasound Abdomen (CPT 76700 or 76705); MRI Abdomen and Pelvis without and with contrast (CPT 74183 and 72197) or without contrast (CPT 74181 and 72195) are medically necessary for suspected postoperative complications (e.g., bowel obstruction, abscess, anastomotic leak) within 60 days post-op.within 60 days post-op

MRI may replace CT only if study can be completed in a similar timeframe for urgent abscess evaluation.

Nuclear medicine for specific postoperative or sepsis scenarios: Radiopharmaceutical nuclear medicine imaging (CPT 78800-78803, 78830-78832) is medically necessary for peritonitis, postoperative fever without localizing signs, and for certain evaluations beyond 60 days post-op as clinically indicated.post-op timing and clinical features

Constipation / Diarrhea / IBS

Constipation, diarrhea, and irritable bowel syndrome

General stance: The overwhelming majority of children with constipation, diarrhea, or IBS do not require advanced imaging; history and physical exam usually suffice.

Advanced imaging reserved for cases with red flag signs or symptoms per PEDAB-1.0.

When CT is medically necessary: CT Abdomen (CPT 74160) or CT Abdomen and Pelvis (CPT 74177) with contrast is medically necessary if red flag signs or symptoms are present.presence of red flags

See PEDAB-1.0 for red flag list.

MRI pelvis post-op Hirschsprung-related: MRI Pelvis without and with contrast (CPT 72197) is medically necessary postoperatively in individuals with signs of complications related to Hirschsprung disease (e.g., assess pull-through bowel, sphincter muscles).postoperative signs of complication

Abdominal Wall and Intra-abdominal Masses

Abdominal wall mass and intra-abdominal mass

Initial imaging for abdominal wall mass: For initial imaging of a newly discovered abdominal wall mass, any of the following are medically necessary: Ultrasound (CPT 76700 or 76705), MRI Abdomen without contrast (CPT 74181) or without and with contrast (CPT 74183); add MRI Pelvis (CPT 72195/72197) if lesion is below the umbilicus.initial evaluation

Ultrasound and MRI are acceptable initial modalities.

When CT is indicated preoperatively: If ultrasound and/or MRI are inconclusive or insufficient for preoperative planning, CT Abdomen with contrast (CPT 74160) or CT Abdomen and Pelvis with contrast (CPT 74177) (or without contrast codes as appropriate) are medically necessary depending on lesion location.inconclusive US/MRI or preoperative planning needs

Choice depends on lesion location relative to umbilicus.

Intra-abdominal mass initial imaging:

Renovascular and Secondary Hypertension

Renovascular hypertension and secondary causes of pediatric hypertension

Initial evaluation prerequisites: Clinical evaluation should include repeated BP measurements (generally ≥3) and diagnosis by trained health professionals; document BP trajectory prior to imaging decisions.≥3 measurements/visits

ABPM may be used for outpatient evaluation.

Imaging medically necessary for suspected secondary hypertension: Doppler or Duplex US (CPT 93975/93976) and complete retroperitoneal US (CPT 76770) are initial imaging; CTA Abdomen (CPT 74175) or MRA Abdomen (CPT 74185) are medically necessary to exclude fibromuscular dysplasia or renal artery lesions when clinical suspicion exists.clinical suspicion of secondary hypertension

Echocardiography (CPT 93306) recommended at initial evaluation.

Nuclear renal imaging indications: Nuclear renal imaging (CPT 78707/78708/78709) is medically necessary for severe or progressive hypertension scenarios (e.g., malignant HTN, failure to respond to therapy, asymmetric kidneys, unexplained creatinine rise, abdominal bruit, recurrent pulmonary edema, hypokalemia with elevated renin, neurofibromatosis-associated HTN).

Renovascular hypertension and related imaging

Imaging for pediatric hypertension and renovascular suspicion

Renovascular imaging modalities: CTA Abdomen (CPT 74175) or MRA Abdomen (CPT 74185) is medically necessary to exclude fibromuscular dysplasia or other blood-flow restricting lesions of the renal arteries and suprarenal aorta in pediatric hypertension.

Doppler US has limited sensitivity for distal intrarenal or accessory renal artery stenosis; CTA/MRA preferred when clinical suspicion high.

When Doppler US insufficient: Children with high clinical suspicion for renin-mediated hypertension should undergo CTA (74175) or MRA (74185) regardless of Doppler US results due to poor sensitivity of US for certain lesions.

Additional cardiac screening: Echocardiography (CPT 93306) is medically necessary at initial evaluation to assess for cardiac causes or end-organ damage such as coarctation and LVH.

Liver lesion characterization and management

Imaging pathways for pediatric liver lesion characterization

Initial imaging for liver lesion: Ultrasound Abdomen (CPT 76700 or 76705) is medically necessary as the initial study in children; MRI is preferred over CT when possible to reduce radiation exposure.

High-risk or concerning US findings: For high-risk individuals or concerning findings on US, MRI Abdomen without and with contrast (CPT 74183) or CT Abdomen with contrast (CPT 74160) is medically necessary. High-risk includes prematurity, chronic liver disease, Beckwith-Wiedemann, familial polyposis, trisomy 18, portosystemic shunts, and other listed conditions.

Indeterminate lesion <3cm: Contrast-Enhanced Ultrasound (CEUS CPT 76978/76979) is indicated for indeterminate lesions <3 cm; if CEUS is indeterminate or unavailable, MRI (74183) or CT (74160) is medically necessary.

Indeterminate lesion >3cm: MRI (CPT 74183) or CT (CPT 74160) is medically necessary for indeterminate lesions >3 cm.

Liver failure/cirrhosis and biliary disease imaging

Imaging for pediatric liver failure, cirrhosis, and biliary disease

Initial liver dysfunction imaging: Liver ultrasound (CPT 76700) with duplex Doppler (CPT 93975) is medically necessary as an initial study prior to CT or MRI for suspected liver failure or cirrhosis in pediatric individuals.

MRI for inconclusive US: MRI Abdomen without and with contrast (CPT 74183) is indicated when ultrasound findings are inconclusive or technically limited and is preferred over CT to reduce radiation exposure.

Repeat US timing: Repeat liver ultrasound (CPT 76705) with duplex Doppler is medically necessary annually for known chronic liver dysfunction or cirrhosis, or sooner with new/worsening findings or suspected portal hypertension.

Biliary atresia pathway: If biliary atresia is suspected after initial ultrasound, hepatobiliary scintigraphy (HIDA) is medically necessary if requested by the surgeon prior to liver biopsy.

Liver elastography

Liver elastography for staging fibrosis

Initial staging: Transient Elastography / VCTE (e.g., Fibroscan CPT 91200) is medically necessary as the initial imaging modality for staging liver fibrosis in suspected chronic liver disease.

MRE indications: Magnetic Resonance Elastography (CPT 76391) is medically necessary when transient elastography fails despite XL-probe, when BMI ≥30, or when there is discordance between clinical picture and transient elastography results.BMI ≥30

Liver elastography (medically necessary conditions)

Medically necessary when ALL of the following apply:

Initial staging: Transient Elastography/VCTE (CPT 91200) is the initial imaging modality for staging liver fibrosis in suspected chronic liver disease.

When MRE is necessary: Magnetic Resonance Elastography (CPT 76391) is medically necessary for ANY of: transient elastography failure despite XL-probe OR BMI ≥30 OR conflict between clinical picture and transient elastography results.

Adrenal lesions

Medically necessary imaging pathway:

Initial study for suspected adrenal mass in neonates/infants: Abdominal ultrasound is the medically necessary initial imaging study for adrenal masses in infants and young children.

Short-interval follow-up: If an adrenal mass is detected, short-interval follow-up retroperitoneal ultrasound (CPT 76770) in 7–10 days is often adequate.

Advanced imaging to confirm neuroblastoma: If repeat ultrasound is concerning for neuroblastoma or there is high clinical concern, MRI Abdomen without and with contrast (CPT 74183) OR CT Abdomen without and with contrast (CPT 74170) are medically necessary to confirm diagnosis; MRI preferred to reduce radiation. If neuroblastoma confirmed, 123I MIBG scintigraphy is medically necessary for staging.

Adrenal nuclear imaging indications: Adrenal nuclear imaging (CPT 78075; MIBG CPT 78800–78804 or hybrid SPECT/CT CPT 78830–78832) is medically necessary to distinguish adenoma from hyperplasia, evaluate suspected pheochromocytoma/paraganglioma, and to evaluate suspected neuroblastoma/ganglioneuroblastoma/ganglioneuroma.

Transfusion-associated hemochromatosis

Medically necessary imaging when managing transfusion-associated iron overload:

Who to screen: Screening MRI annually is medically necessary for chronically transfused individuals at risk for transfusion-associated hemochromatosis (typically >20 transfusion episodes).interval=12 months

Treatment response monitoring: Imaging every 3 months is medically necessary for individuals receiving active treatment (chelation and/or phlebotomy).interval=3 months

Appropriate modalities: T2* MRI techniques: MRI Abdomen without contrast (CPT 74181) for liver iron; MRI Cardiac without contrast (CPT 75557) for cardiac iron; MRI Chest without contrast (CPT 71550) may be approved as a single study to evaluate both heart and liver iron burden. If CPT 71550 is used it should not be approved with other codes.

Indeterminate renal lesion

Medically necessary imaging for characterization and management:

When MRI/CT are indicated: MRI Abdomen without and with contrast (CPT 74183) OR CT Abdomen with contrast (CPT 74160) is medically necessary for symptomatic simple renal cysts when surgery is being considered.

Complex cysts: MRI Abdomen without and with contrast (CPT 74183) OR CT Abdomen without and with contrast (CPT 74170) is medically necessary for pediatric individuals with complex renal cyst identified on ultrasound.

Functional and reflux assessment: For congenital anomalies, nuclear medicine diuretic renography (CPT 78708/78709) is medically necessary to determine function; cystography is necessary to assess for vesicoureteral reflux.

Solid renal masses: Individuals with solid renal masses should follow Pediatric Renal Tumors guidance (PEDONC-7) in the Pediatric Oncology Imaging Guidelines.

Hydronephrosis

Medically necessary ultrasound and further imaging depending on presentation:

Antenatal hydronephrosis evaluation: Evaluation of antenatal hydronephrosis (AHN) with retroperitoneal ultrasound (CPT 76771) is indicated.

Postnatal ultrasound timing: Postnatal ultrasound within 24 hours is medically necessary for males with distended bladder or infants with moderate/severe antenatal hydronephrosis; postnatal ultrasound after seven days of life is medically necessary for infants with mild prenatal hydronephrosis.

Second postnatal scan: A second postnatal ultrasound at 4–6 weeks of age is medically necessary for all infants with antenatal hydronephrosis.

Ongoing follow-up: Infants with known hydronephrosis may be followed by ultrasound every 3–12 months until resolution.interval=3-12 months

Polycystic Kidney Disease imaging

Covered when any of the following apply:

PKD imaging: Abdominal ultrasound (CPT 76700) or retroperitoneal ultrasound (CPT 76770) is medically necessary for clinical concern of polycystic kidney disease or for screening individuals at risk for autosomal dominant polycystic kidney disease (ADPKD).

MRI-based diagnostic criteria are not established for children <15 years; MRI indications for older children align with adult guidance.

Blunt abdominal trauma

Covered when adult indications apply to pediatric patients:

Blunt trauma: Blunt abdominal trauma imaging indications in pediatric individuals are identical to adult indications; follow adult blunt abdominal trauma guideline for modality selection.

Hernia imaging

Covered when adult indications apply to pediatric patients:

Hernia imaging indications in pediatric individuals are identical to adult indications; follow adult hernia guideline for modality selection.

Abdominal lymphadenopathy

Covered when adult indications apply to pediatric patients:

Lymphadenopathy: Abdominal lymphadenopathy imaging indications in pediatric individuals are identical to adult indications; follow adult abdominal lymphadenopathy guidance.

Left upper quadrant pain

Covered when any of the following are met:

LUQ pain: Left upper quadrant pain imaging indications in pediatric individuals mirror adult guidance; nuclear medicine spleen imaging (CPT 78185) is medically necessary when ultrasound and CT are unavailable.

Spleen imaging

Covered when any of the following indications are present:

Spleen indications: Nuclear medicine spleen imaging (CPT 78185; or CPT 78215/78216 if requested) is medically necessary for splenic trauma, evaluation of splenic function, suspected splenic mass/cyst/abscess/infarct/metastasis, radiation treatment planning, asplenia, or suspected functional accessory spleen. MRI is preferred over CT when possible to reduce radiation exposure in pediatric patients.

Intussusception (diagnostic criteria)

Covered when ALL of the following are met:

Intussusception coverage: Ultrasound (CPT 76700 or 76705) is medically necessary as the initial diagnostic study when there is strong clinical suspicion of intussusception.

CT Abdomen and/or Pelvis with contrast (CPT 74160 or 74177) is medically necessary to characterize or diagnose pathologic lead points identified on ultrasound.

Intussusception (management/pathway)

Covered when ALL of the following are met

Intussusception initial study: Ultrasound (CPT 76700 or 76705) is medically necessary as an initial diagnostic study when there is strong suspicion for intussusception.

CT for lead points: CT Abdomen and/or Pelvis with contrast (CPT 74160 or CPT 74177) is medically necessary to help characterize or diagnose pathologic lead points identified on ultrasound.

Bowel Obstruction

Covered when ANY of the following are met depending on suspected obstruction severity and availability

Suspected high-grade obstruction: MRI Abdomen and Pelvis without and with contrast (CPT 74183 and CPT 72197) is medically necessary and preferred to avoid radiation; if MRI not readily available, CT Abdomen and Pelvis with contrast (CPT 74177) is medically necessary.

Suspected intermittent or low-grade SBO: MRI Abdomen and Pelvis without and with contrast (CPT 74183 and CPT 72197) is medically necessary (preferred); CT Abdomen and Pelvis with contrast (CPT 74177) is medically necessary if MRI unavailable.

Additional imaging after CT: If etiology or level remains undetermined after CT, CT enteroclysis/enterography (CPT 74176/74177) or MR enteroclysis/enterography (CPT 74183 and CPT 72197) are medically necessary.

Left Lower Quadrant Pain

Covered when ALL of the following are met

Red flags present: CT Abdomen and Pelvis (CPT 74177) with contrast is medically necessary if any red flag sign or symptom is present for left lower quadrant pain.

In absence of red flags, advanced imaging is rarely helpful initially; pelvic ultrasound (CPT 76856) is initial study of choice to detect gynecologic causes.

Male or inconclusive US: For male individuals or if ultrasound is inconclusive, advanced imaging may be appropriate per gastroenterology consultation to guide management.

Celiac Disease (Sprue)

Uncomplicated celiac disease: Radiological small bowel imaging is not needed in uncomplicated celiac disease; imaging guidance aligns with adult guidance where applicable.

Transplant imaging indications

Post-transplant imaging: Liver and kidney transplant imaging indications in pediatric individuals align with adult transplant imaging guidance; follow transplant and oncology-specific sections for PTLD evaluation.

Vomiting Infant, Malrotation, Hypertrophic Pyloric Stenosis

Malrotation with midgut volvulus suspected: If malrotation with midgut volvulus is suspected, emergent limited abdominal ultrasound (CPT 76705) is medically necessary.

Hypertrophic pyloric stenosis suspected: Limited abdominal ultrasound (CPT 76705) is medically necessary for infants with persistent projectile non-bilious vomiting; if initial studies are nondiagnostic, repeat studies are medically necessary and may be performed as frequently as daily until diagnosis or resolution.

Gaucher Disease imaging

Gaucher disease guidance: Refer to Gaucher Disease topic in Pediatric Peripheral Nerve and Neuromuscular Disorders Imaging Guidelines (PEDPN-4) for condition-specific imaging guidance.

Vomiting — malrotation/midgut volvulus

Covered when ALL of the following are met

Malrotation/midgut volvulus: Suspected malrotation with volvulus is an indication for emergent imaging; limited abdominal ultrasound (CPT 76705) is medically necessary.

Supports emergent ultrasound for suspected volvulus.

Vomiting — hypertrophic pyloric stenosis

Covered when ALL of the following are met

Hypertrophic pyloric stenosis (HPS): Ultrasound abdomen, limited (CPT 76705) is medically necessary for infants with persistent projectile non-bilious vomiting; if initial studies are not diagnostic, repeat limited ultrasound as frequently as daily is medically necessary until vomiting resolves or diagnosis is confirmed.

Repeat daily imaging permitted until diagnosis or resolution.

Acute pancreatitis imaging

Covered when ANY of the following are met

Red flag present: If red flag findings per General Guidelines are present, CT Abdomen and Pelvis with contrast (CPT 74177), CT Abdomen with contrast (CPT 74160), or MRI/MRCP (CPT 74183 or CPT 74181) is medically necessary for acute pancreatitis evaluation.

Red flag presence supersedes other criteria.

Initial imaging for suspected acute pancreatitis: Ultrasound Abdomen (CPT 76700 or 76705) is medically necessary as initial imaging for suspected acute pancreatitis.

Ultrasound is first-line.

Ultrasound nondiagnostic or persistent suspicion: If ultrasound is nondiagnostic due to technical limitation or clinical suspicion persists, MRI/MRCP (CPT 74183 or CPT 74181) is medically necessary; if MRI/MRCP cannot be performed, CT Abdomen and Pelvis with contrast (CPT 74177) or CT Abdomen with contrast (CPT 74160) is medically necessary.

Escalation pathway specified.

Chronic pancreatitis imaging

Covered when ALL of the following are met

Chronic pancreatitis suspected: MRI Abdomen without and with contrast (CPT 74183) is medically necessary for suspected chronic pancreatitis; if MRI cannot be performed, CT Abdomen and Pelvis with contrast (CPT 74177) or CT Abdomen with contrast (CPT 74160) is medically necessary.

Imaging choices for chronic pancreatitis prioritize MRI when feasible.

Evaluate acute episode in chronic pancreatitis: To evaluate suspected or known acute pancreatitis in a child with chronic pancreatitis, abdominal ultrasound (CPT 76700/76705) is medically necessary; CT (CPT 74177/74160) or MRI/MRCP (CPT 74183/74181) are medically necessary if ultrasound is negative and imaging diagnosis is required or for planning endoscopic or surgical interventions.

Specifies modality selection in chronic disease.

Studies, procedures, or devices lacking sufficient supporting evidence, demonstrable clinical utility, or widespread professional acceptance are considered investigational/experimental. Examples include interventions with a paucity of peer‑reviewed evidence, immature evidence that has not demonstrated improved health outcomes, or absence of a collective professional opinion in support. Requests for such services will be reviewed against these criteria and may be denied as investigational.

The policy does not generally support PET/MRI and does not permit unbundling a combined PET/CT into separate PET and diagnostic CT CPT codes. PET/MRI may only be considered when condition‑specific PET/MRI criteria are met or when PET/CT criteria are met and PET/CT is unavailable; when approved, report PET whole‑body (e.g., CPT 78813) plus an appropriate unlisted MRI code (e.g., CPT 76498) per the guideline.

Condition-Specific Covered Indications

See condition-specific PEDAB sections for indication-based imaging criteria

See condition-specific PEDAB sections for indication-based imaging criteria.

Condition-specific sections: Refer to the individual PEDAB condition sections (e.g., appendicitis, UTI, IBD, liver disease, hydronephrosis, trauma, pancreatitis) for detailed indication-based imaging criteria and modality selection.

This block directs reviewers to condition-specific guidance.

Modality-specific appropriate uses

Ultrasound indications: Initial evaluation of soft tissue masses, differentiation of adenopathy from cyst/mass, obstetric/gynecologic imaging, visceral abdominal/pelvic imaging, procedural guidance, and vascular imaging when not obscured by bone; operator-dependent quality considerations apply.

Ultrasound is first-line in most pediatric abdominal conditions.

CT indications: Screening after trauma, pulmonary disease imaging, evaluation of abdominal and pelvic viscera, complex fractures, and when rapid acquisition or broader field of view is needed; use CT with or without contrast per condition-specific guidance.

Consider radiation risks in pediatric populations; CT should not replace MRI solely to avoid sedation unless supported.

MRI indications: Characterizing soft-tissue masses, CNS/spine imaging, resolving inconclusive ultrasound or CT findings, pregnancy considerations, and when avoiding ionizing radiation is important; MRI contrast use should be limited to circumstances where additional information alters management.

Gadolinium considerations and renal function cautions apply (GFR <30 mL/min).

3D rendering for complex anatomic evaluation and pre-operative planning

3D rendering indication node: 3D rendering (CPT 76376/76377) may be considered for complex bony reconstructions (congenital skull abnormalities, complex fractures), spine/pelvic/intra‑articular fracture planning, complex facial fractures, cerebral angiography planning, CT urogram or MRCP when conventional imaging is insufficient, and other pre-operative planning scenarios where 3D visualization changes surgical approach.

Documentation of physician supervision/participation in rendering is recommended.

Imaging guidance for percutaneous procedures and ablations

Guidance imaging indication: CT/MR/US guidance codes (e.g., 76942, 77011–77022, 75989) are indicated for needle placement, catheter drainage with catheter left in place, stereotactic localization scans, and monitoring during ablation procedures; guidance codes include the imaging necessary for the procedure and should be used instead of routine diagnostic imaging codes for the same encounter.

Only percutaneous procedures should be billed with guidance codes; documentation should support the billed guidance service.

SPECT/CT for localization/attenuation correction and selected nuclear medicine studies

SPECT/CT Indications: SPECT/CT (CPT 78830–78832 or CPT 78072 for parathyroid) combines functional nuclear imaging with CT for anatomic localization and attenuation correction; commonly used for MIBG, octreotide, and parathyroid studies when localization or hybrid imaging is required.

Use modality-appropriate codes for hybrid studies.

Whole-body MRI limited indications

WBMRI exceptions: Whole-body MRI is generally not supported except for select cancer predisposition syndromes and certain autoimmune conditions (e.g., chronic recurrent multifocal osteomyelitis); coding/reporting uses CPT 76498 for WBMRI.

WBMRI lacks standardization and demonstrated outcome benefit for most indications.

Limited/follow-up CT use

Limited CT guidance: CPT 76380 is used for limited or follow-up CT studies in which full diagnostic CT work is not performed (e.g., limited sinus CT, targeted follow-up slices). It is not appropriate for treatment planning and should not be used to cover extra slices in conjunction with diagnostic CT codes.

Clinical justification should explain why full diagnostic CT work was not performed.

Suspected Meckel's diverticulum

Meckel's imaging: Nuclear intestinal/gastric mucosa imaging (e.g., CPT 78290 or CPT 78261) is indicated for suspected Meckel's diverticulum when clinically appropriate.ANY

Use institutional protocols for pediatric dosing and interpretation.

Suspected gastric emptying abnormalities

Gastric emptying studies: Gastric emptying study (CPT 78264) is indicated for suspected delayed or rapid gastric emptying; variants with small-bowel transit (CPT 78265) or combined small-bowel/colon transit (CPT 78266) may be used when regional transit assessment is needed.ANY

Follow pediatric protocol recommendations.

Generalized abdominal pain

Generalized abdominal pain pathway: Ultrasound initial when no red flags, normal exam, and normal labs; CT with contrast (CPT 74160 or 74177) if any red flags present; localize to quadrant-specific guidelines when appropriate.

GI consultation may help determine need for advanced imaging.

Generalized abdominal pain (duplicate)

Generalized abdominal pain

Initial evaluation: When no red flags and evaluation nonfocal, ultrasound (CPT 76700/76705) is medically necessary as initial imaging; escalate to CT/MRI only per red flag presence or inconclusive US.

Document labs and clinical exam supporting imaging choice.

Coding — Procedure Codes and Guidance

Experimental/Investigational CPTCPTExperimental

C9791

MRI utilizing Xenon Xe 129 (contrast) — considered investigational/experimental in this guidance

3D Rendering CPT CodesCPTCovered

76376	3D rendering; not requiring image post-processing on an independent workstation
76377	3D rendering; requiring image post-processing on an independent workstation

Imaging guidance, biopsy, drainage, and unlisted procedure codesCPTCovered

19085	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including MR guidance
19086	Biopsy, breast... each additional lesion, including MR guidance
75989	Imaging guidance for percutaneous drainage with placement of catheter (all modalities)
76942	Ultrasonic guidance for needle placement
77011	CT guidance for stereotactic localization
77012	CT guidance for needle placement
77013	CT guidance for, and monitoring of parenchymal tissue ablation
77021	MR guidance for needle placement
77022	MR guidance for, and monitoring of parenchymal tissue ablation
76497	Unlisted CT procedure (diagnostic or interventional)

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Covered CPT Codes (Abdomen and related procedures)CPTCovered

74181	MRI Abdomen without contrast
74182	MRI Abdomen with contrast
74183	MRI Abdomen without and with contrast
76498	Unlisted MRI procedure (for radiation planning or surgical software)
74185	MRA Abdomen
74150	CT Abdomen without contrast
74160	CT Abdomen with contrast
74170	CT Abdomen without and with contrast
74176	CT Abdomen and Pelvis without contrast
74177	CT Abdomen and Pelvis with contrast

1–10 of 14

1/2

Covered CPT Codes (CTA, PET, Nuclear Medicine)CPTCovered

76497	Unlisted CT procedure (for radiation planning or surgical software)
74175	CTA Abdomen
74174	CTA Abdomen and Pelvis
78811	PET Imaging; limited area (not used in pediatrics)
78812	PET Imaging: skull base to mid-thigh (not used in pediatrics)
78813	PET Imaging: whole body (not used in pediatrics)
78814	PET with concurrently acquired CT; limited area (rarely used in pediatrics)
78815	PET with concurrently acquired CT; skull base to mid-thigh
78816	PET with concurrently acquired CT; whole body
78075	Adrenal Nuclear Imaging Cortex and/or Medulla

1–10 of 17

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SPECT/CT CodesCPTCovered

78830	SPECT/CT single area and single day
78831	SPECT/CT 2 or more days
78832	SPECT/CT 2 areas with one day and 2-day study
78072	SPECT/CT parathyroid nuclear imaging (effective 1/1/2013)

Limited CT / Unlisted guidanceCPT

76380

Limited or Follow-up CT

Common MRI/CT/CT-guidance CPT codesCPT

74181	MRI Abdomen without contrast
74182	MRI Abdomen with contrast
74183	MRI Abdomen without and with contrast
76498	Unlisted MRI procedure (for radiation planning or surgical software)
74185	MRA Abdomen
74150	CT Abdomen without contrast
74160	CT Abdomen with contrast
74170	CT Abdomen without and with contrast
74176	CT Abdomen and Pelvis without contrast
74177	CT Abdomen and Pelvis with contrast

1–10 of 14

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CTA, PET, and nuclear medicine codesCPT

76497	Unlisted CT procedure (for radiation planning or surgical software)
74175	CTA Abdomen
74174	CTA Abdomen and Pelvis
78811	PET limited area
78812	PET skull base to mid-thigh
78813	PET whole body
78814	PET with CT limited area
78815	PET with CT skull base to mid-thigh
78816	PET with CT whole body
78075	Adrenal Nuclear Imaging Cortex and/or Medulla

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Nuclear medicine and functional GI/kidney codesCPT

78261	Gastric mucosa imaging / alternate Meckel's scan code (also gastroesophageal reflux study mapping in doc)
78264	Gastric Emptying Study
78278	GI Bleeding Scintigraphy
78282	Gastrointestinal Protein Loss
78290	Intestinal Imaging (Meckel's scan preferred)
78291	Peritoneal-Venous Shunt Patency
78700	Kidney Imaging (Nuclear) Static
78701	Kidney Imaging with Vascular Flow
78707	Kidney Flow and Function, Single Study
78708	Kidney Imaging with Pharmacological Intervention

1–10 of 16

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Ultrasound and duplex codesCPTCovered

76700	Ultrasound, abdomen; complete
76705	Ultrasound, abdomen; limited
76770	Ultrasound, retroperitoneal; complete
76775	Ultrasound, retroperitoneal; limited
76776	Ultrasound, transplanted kidney (with duplex Doppler)
93975	Duplex scan abdominal/pelvic/retroperitoneal complete
93976	Duplex scan abdominal/pelvic/retroperitoneal limited
93978	Duplex aorta/IVC/iliac complete
93979	Duplex aorta/IVC/iliac limited

Generalized and appendicitis imaging CPTsCPTCovered

76700	Ultrasound abdomen, general
76705	Ultrasound abdomen with limited study (pediatrics listed)
74160	CT abdomen with contrast (single region)
74177	CT abdomen and pelvis with contrast

MRI for appendicitis/advanced abdominal imagingCPTCovered

74181	MRI abdomen and pelvis without contrast (listed as abdomen and pelvis MRI)
72195	MRI pelvis without contrast
74183	MRI abdomen and pelvis without and with contrast (MRU mentioned)
72197	MRI pelvis without and with contrast

Renal/urinary tract imaging CPTsCPTCovered

76770	Ultrasound, kidney, bilateral with bladder
76775	Ultrasound, other kidney/urinary structures (pediatric variants)
74176	CT abdomen and pelvis without contrast
78707	Diuretic renography (MAG3) — imaging
78708	Diuretic renography (MAG3) — quantification
78709	Diuretic renography (MAG3) — delayed imaging
78803	DMSA renal cortical imaging (planar)
78740	Radiopharmaceutical voiding cystogram (radionuclide cystography)
78700	DMSA renal cortical imaging, initial
78701	DMSA renal cortical imaging, subsequent

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Hematuria—medically necessary imaging CPTsCPTCovered

76770	Ultrasound, limited or single organ, kidney(s) (from doc: Ultrasound kidneys)
76775	Ultrasound, complete, kidney(s) (from doc: Ultrasound kidneys)
76856	Ultrasound, bladder, limited (from doc: Ultrasound bladder)
76857	Ultrasound, bladder, complete (from doc: Ultrasound bladder)
74176	CT Abdomen and Pelvis without contrast
74177	CT Abdomen and Pelvis with contrast
72193	CT Pelvis with bladder contrast (CT cystography)
76377	3-D reconstruction services
76376	3-D rendering with interpretation and reporting

Right upper quadrant pain—medically necessary imaging CPTsCPTCovered

76700	Ultrasound abdomen, general (US Abdomen)
78226	Hepatobiliary scintigraphy (HIDA) - without quantitation
78227	Hepatobiliary scintigraphy (HIDA) - with quantitation
74160	CT Abdomen with contrast
74181	MRI Abdomen without contrast
74183	MRI Abdomen without and with contrast (or MR enterography per grouping)

Inflammatory Bowel Disease—enterography and pelvic MRI CPTsCPTCovered

74183	MR Enterography / MRI Abdomen without and with contrast
74181	MRI Abdomen without contrast (used in MR Enterography combinations)
72197	MRI Pelvis without and with contrast (used with MR enterography)
72195	MRI Pelvis without contrast
74177	CT Enterography / CT Abdomen and Pelvis with contrast
72196	MRI Pelvis with contrast

Referenced nuclear medicine procedures (not enumerated as CPTs in excerpt)mixed

DMSA procedures (referenced in refs)

Nuclear medicine renal cortical scintigraphy (referenced guideline Vali et al.)

Medically necessary studies for postoperative complications and sepsisCPTCovered

74177	CT Abdomen and Pelvis with contrast
76700	Ultrasound Abdomen
76705	Ultrasound Abdomen (complete or limited as per payer listing)
74183	MRI Abdomen and Pelvis without and with contrast
72197	MRI Pelvis without and with contrast
74181	MRI Abdomen without contrast
72195	MRI Pelvis without contrast
78800	Radiopharmaceutical nuclear medicine imaging (unspecified)
78801	Radiopharmaceutical nuclear medicine imaging (unspecified)
78802	Radiopharmaceutical nuclear medicine imaging (unspecified)

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Imaging for abdominal wall and intra-abdominal massesCPTCovered

76700	Ultrasound (initial imaging for abdominal wall mass)
76705	Ultrasound (as alternative initial imaging)
93975	Ultrasound with Doppler (vascular supply evaluation)
74181	MRI Abdomen without contrast
74183	MRI Abdomen without and with contrast
72195	MRI Pelvis without contrast
72197	MRI Pelvis without and with contrast
74160	CT Abdomen with contrast
74150	CT Abdomen without contrast
74177	CT Abdomen and Pelvis with contrast

1–10 of 11

1/2

Imaging for renovascular hypertension / secondary hypertension evaluationCPTCovered

93975	Doppler or Duplex Ultrasound
93976	Duplex study (alternate code listed)
76770	Complete retroperitoneal Ultrasound
74175	CTA Abdomen
74185	MRA Abdomen
93306	Echocardiography
78707	Nuclear renal imaging (capability unspecified)
78708	Nuclear renal imaging (capability unspecified)
78709	Captopril renography / nuclear renal imaging

CT for GI symptoms with red flagsCPTCovered

74160	CT Abdomen with contrast (for constipation/diarrhea with red flags)
74177	CT Abdomen and Pelvis with contrast (for constipation/diarrhea/IBS with red flags)

Renal and cardiac imagingCPTCovered

74175	CTA Abdomen
74185	MRA Abdomen
93306	Echocardiography (initial evaluation)
78707	Nuclear renal imaging
78708	Nuclear renal imaging
78709	Nuclear renal imaging

Liver lesion and nuclear imagingCPTCovered

76700	US Abdomen (initial study)
76705	Repeat or limited US Abdomen
74183	MRI Abdomen without and with contrast (including MRCP variants)
74160	CT Abdomen with contrast
76978	Contrast-Enhanced US (CEUS) per lesion
76979	Contrast-Enhanced US (CEUS) per additional component
78201	Nuclear medicine liver imaging
78202	Nuclear medicine liver imaging
78803	Nuclear medicine liver imaging
78215	Nuclear medicine for accessory spleen (liver/spleen)

1–10 of 11

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Ultrasound duplex and elastographyCPTCovered

93975	Duplex Doppler exam
93976	Duplex Doppler follow-up/alternate
91200	Transient Elastography (Fibroscan)
76391	Magnetic Resonance Elastography (MRE)

Liver elastography CPT codesCPTCovered

91200	Transient Elastography (e.g., Fibroscan)
76391	Magnetic Resonance Elastography (MRE)

Adrenal and renal imaging CPT codesCPTCovered

76770	Retroperitoneal ultrasound (follow-up)
76771	Prenatal/postnatal retroperitoneal ultrasound (antenatal hydronephrosis evaluation)
74183	MRI Abdomen without and with contrast
74170	CT Abdomen without and with contrast
74160	CT Abdomen with contrast

Hemochromatosis MRI CPT codesCPTCovered

74181	MRI Abdomen without contrast (liver iron evaluation)
75557	MRI Cardiac without contrast (cardiac iron evaluation)
71550	MRI Chest without contrast (can evaluate heart and liver iron burden)

Nuclear medicine renography CPT codesCPTCovered

78707	Diuretic renography
78708	Diuretic renography
78709	Diuretic renography

Adrenal nuclear imaging/MIBG CPT codesCPTCovered

78800	MIBG planar imaging
78801	MIBG planar imaging
78802	MIBG planar imaging
78803	MIBG SPECT
78804	MIBG SPECT
78830	Hybrid SPECT/CT
78831	Hybrid SPECT/CT
78832	Hybrid SPECT/CT

Polycystic Kidney Disease - Covered CPT CodesCPTCovered

76700	Abdominal ultrasound
76770	Retroperitoneal ultrasound
74181	MRI abdomen without contrast

Spleen - Nuclear Medicine CPT CodesCPTCovered

78185	Splenic imaging (nuclear medicine)
78215	Splenic imaging, alternate nuclear medicine code
78216	Splenic imaging, alternate nuclear medicine code

Intussusception - Preferred and secondary CPT CodesCPTCovered

76700	Abdominal ultrasound (intussusception initial study)
76705	Limited abdominal ultrasound (intussusception)
74160	CT abdomen and pelvis with contrast
74177	CT abdomen and pelvis with contrast (alternate)

Referenced CPT Codes for modalitiesCPT

76700	Ultrasound, abdominal, real time with image documentation; limited (e.g., single quadrant, follow-up).
76705	Ultrasound, abdominal, real time with image documentation; complete.
74160	Computed tomography, abdomen; with contrast material(s).
74177	Computed tomography, abdomen and pelvis; with contrast material(s).
74176	Computed tomography, abdomen; with contrast material, without pelvis (enteroclysis listed as option).
74183	Magnetic resonance imaging, abdomen, without and with contrast material(s).
72197	Magnetic resonance imaging, pelvis, without and with contrast material(s).
76856	Ultrasound, pelvic (nonobstetric), real time with image documentation; limited.

Relevant imaging CPT codesCPT

76705	Ultrasound abdomen, limited (US Abdomen, limited)
76700	US Abdomen (general)
74177	CT Abdomen and Pelvis with contrast
74160	CT Abdomen with contrast
74183	MRI Abdomen without and with contrast / MRI/MRCP (as listed)
74181	MRI/MRCP (alternate code listed)

GFR threshold

GFR cutoff for contrast avoidanceGFR < 30 mL/min (avoid gadolinium or iodinated contrast unless benefits outweigh risks)

Risk equivalence noteBoth CT and MRI contrast carry similar increased risk in renal failure (GFR <30 mL/min)

NSF concernGadolinium exposure in low GFR patients increases risk of nephrogenic systemic fibrosis (NSF)

Units for guidance codes

Unit reporting rule for guidance codesOnly one unit of any imaging guidance code (e.g., 77012, 77021, 76942, 77002–77003, 77013/77022) should be reported per individual encounter (date of service)

Unit of service definitionThe unit of service is the individual encounter, not the number of lesions or localizations performed during that encounter

Guidance code examplesApplies to CT/MR/US/fluoroscopy guidance codes used for needle placement, ablation monitoring, and similar percutaneous procedures

Sequences/slices for CT

CPT position on slice/sequence countsThere is no specific minimum or maximum number of CT sequences or slices defined by CPT; AMA does not assign slice/sequence counts for CT codes

Clinical justificationCT protocols and number of slices/sequences should be tailored to the individual's clinical situation and documented as needed

Limited CT (76380) relevanceLimited CT (CPT 76380) is used when full diagnostic code work is not performed; it should not be used to cover 'extra slices' with other diagnostic CT codes

Anesthesia consideration for MRI

Anesthesia requirement for pediatric MRIAnesthesia is usually required for almost all infants (except neonates) and children <7 years, and for older children with developmental delays, to minimize motion during MRI

Opportunity to limit anesthesia exposuresIf IV access is present for anesthesia, acquiring MRI without and with contrast in the same session may avoid repeat anesthesia events

Session planning considerationPlan MRI sessions to obtain all necessary body areas concurrently to minimize anesthesia exposure

BMI threshold for alternate imaging

BMI threshold to favor CT/MRI over ultrasoundBMI ≥ 85th percentile for age — consider CT or MRI instead of ultrasound when ultrasound is likely to be nondiagnostic

Context of useApplied in appendicitis and other scenarios where ultrasound sensitivity is reduced by obesity

Document rationaleDocument rationale (e.g., BMI percentile) when selecting advanced imaging over ultrasound

Fecal lactoferrin threshold

Fecal lactoferrin threshold for IBD evaluation>= 4.0 ug/g

Use in contextConsider enterography or advanced imaging when fecal lactoferrin meets or exceeds threshold alongside clinical concern for Crohn disease

Combined marker interpretationInterpret with other clinical and endoscopic findings when deciding imaging necessity

CRP threshold

CRP threshold for IBD consideration> 0.5 mg/dL

Role in imaging decisionElevated CRP above threshold supports need for MR/CT enterography in suspected Crohn disease

Combine with other dataUse alongside fecal calprotectin, fecal lactoferrin, endoscopy, and clinical features

Fecal calprotectin threshold

Fecal calprotectin threshold for IBD evaluation>= 50 ug/g

Imaging implicationValue at or above threshold supports MR Enterography or CT Enterography when clinical suspicion for Crohn disease exists

Integration with other findingsConsider endoscopy and other inflammatory markers when deciding imaging pathway

BP measurement repetition

Blood pressure measurement repetition for pediatric HTN workupObtain ≥3 BP measurements on different visits to support diagnosis of pediatric hypertension

Diagnosis requirementDiagnosis of hypertension made by trained professionals using auscultatory-confirmed readings ≥95th percentile at 3 visits

ABPM useAmbulatory blood pressure monitoring (ABPM) may be used for outpatient evaluation and confirmation

BMI threshold for MRE

BMI threshold for MRE indicationBMI ≥ 30 — MRE medically necessary when transient elastography fails or BMI ≥30

Role relative to TEMRE (CPT 76391) indicated when TE (Fibroscan) fails despite XL-probe or results discordant with clinical picture

Initial testTransient elastography (CPT 91200) is the initial staging test; proceed to MRE per above criteria

Transfusion exposure threshold

Transfusion exposure threshold for iron overload risk>20 transfusion episodes — consider screening for transfusion-associated hemochromatosis

Populations at riskMost common in sickle cell disease, thalassemia, bone marrow failure, oncology, and transplant patients

Clinical actionInitiate T2* MRI screening and monitoring when exposure exceeds threshold

BMI threshold for MRE consideration (duplicate)

BMI threshold for MRE consideration (repeat)BMI ≥ 30 — MRE indicated when transient elastography fails or BMI ≥30

RationaleHigher BMI can limit transient elastography accuracy; MRE provides reliable assessment

Coding noteMRE reported with CPT 76391 when indicated

Provider Actions — Prior Auth, Documentation & Denial Risks

Denial Risk

Advanced imaging requests may be denied

Advanced imaging requests may be denied if the clinical documentation is insufficient, if the requested study is duplicative of recent imaging without evidence of progression or new disease, or if less invasive/ lower-cost modalities would adequately address the clinical question. Requests lacking a pertinent clinical evaluation since symptom onset or change (detailed history, physical exam, relevant labs, prior imaging) are at increased risk for denial.

Denial risk: insufficient clinical evaluation or missing documentation
Denial risk: repeat imaging of same body area without progression, new disease, or clear impact on management
Denial risk: advanced imaging for screening asymptomatic individuals (abdomen)

Denial Risk

Repeat imaging of the same body area may be denied

Repeat imaging of the same body area is generally not supported unless there is documentation of disease progression, recurrence, new onset disease, or clear documentation showing how the repeat imaging will affect patient management or treatment decisions. Scheduled guideline-supported surveillance imaging and some postoperative follow-up scenarios are exceptions.

Repeat imaging permitted when evidence of progression/recurrence/new disease is documented
Scheduled or guideline-supported surveillance imaging is allowed (e.g., post-op hydronephrosis follow-up, chronic liver disease surveillance)

Denial Risk

Advanced imaging is not medically necessary in many scenarios

Advanced imaging is not medically necessary for many common pediatric abdominal conditions in the absence of red flag signs or symptoms, when the results would not affect management, or when less invasive testing (including ultrasound) adequately addresses the clinical question. Examples include uncomplicated acute gastroenteritis, routine screening of asymptomatic individuals, and asymptomatic microscopic hematuria without proteinuria.

Not medically necessary: advanced imaging for pediatric acute gastroenteritis without concern for alternative diagnosis
Not medically necessary: whole-body CT or whole-body MRI for routine screening
Not medically necessary: imaging for asymptomatic microscopic hematuria without proteinuria

Documentation Required

For suspected Crohn disease, initial evaluation and imaging expectations

For suspected Crohn disease, initial evaluation typically includes laboratory testing and upper and lower endoscopy. Advanced small-bowel imaging (MR enterography or CT enterography, or MRI abdomen/pelvis without and with contrast) is medically necessary to detect disease distribution, assess severity, or identify complications, but should be requested only when indicated by clinical features, endoscopy findings, family history, or elevated inflammatory markers.

Medically necessary: MR Enterography (CPT 74183/74181 + pelvic codes) or CT Enterography (CPT 74177) to evaluate suspected Crohn disease when indicated
Indications include: positive family history, endoscopy/colonoscopy suggesting IBD, or elevated inflammatory markers (fecal lactoferrin ≥4.0 µg/g, CRP >0.5 mg/dL, fecal calprotectin ≥50 µg/g)
MR or CT enterography may be performed prior to endoscopy if requested by the endoscopist

Prior Authorization

Ultrasound or nuclear medicine (HIDA) are appropriate initial modalities

Ultrasound or nuclear medicine (HIDA) are appropriate initial modalities for many pediatric right upper quadrant complaints. Ultrasound is the preferred initial study for suspected acute cholecystitis, biliary disease, and many hepatobiliary problems; HIDA (CPT 78226/78227) is medically necessary for diagnosis when indicated, and MRI or CT are reserved for equivocal or inconclusive ultrasound/HIDA results or higher-acuity presentations.

Initial imaging for RUQ pain: US Abdomen (CPT 76700) and/or HIDA (CPT 78226 or 78227)
MRI Abdomen with/without contrast (CPT 74183/74181) or CT Abdomen with contrast (CPT 74160) when US or HIDA is equivocal or if clinical course warrants escalation
Ultrasound results are not required prior to ordering HIDA when clinically indicated

Frequency Limits and Surveillance Intervals

Any — repeat imaging only when evidence of progression/recurrence or will change management

Repeat imaging general ruleRepeat imaging only when there is evidence of disease progression, recurrence, or when repeat imaging will change clinical management

Documentation requirementDocumentation should demonstrate how repeat imaging will affect management or treatment decisions

Exception — guideline-scheduled follow-upScheduled follow-up imaging per specific guideline sections (e.g., antenatal hydronephrosis, liver lesion surveillance) is acceptable

any — repeat imaging not supported without evidence of progression/new disease or documentation of management impact

Repeat imaging unsupported without clinical evidenceRepeat imaging is not supported without evidence of progression/new disease or documentation that the repeat study will change management

Prior imaging reviewReview prior imaging and clinical history before approving repeat advanced imaging to avoid overutilization

Denial riskRequests lacking pertinent clinical evaluation or prior imaging review may be denied

CT Abdomen (74160/74170) or MRI Abdomen (74183) — surveillance interval

Surveillance interval for CT Abdomen (74160/74170) or MRI Abdomen (74183)Every 6 months for 2 years, then annually

Indication exampleSpecifically cited for surveillance of suspected hepatic adenoma to assess growth and malignant transformation

Modality selectionMRI preferred over CT when feasible to reduce radiation exposure

Ultrasound Abdomen (76700/76705) — surveillance interval

Ultrasound abdomen surveillance intervalLimited ultrasound at 6–12 months; surveillance ultrasound every 6–12 months until 2 years

Applies toHepatic hemangioma and simple hepatic cyst follow-up pathways

If increasing sizeIf lesion increases in size, follow-up every 3–6 months or consider biopsy

Ultrasound Abdomen and MRI/MRCP — biannual/triannual schedule

Biannual/triannual schedule for ultrasound and MRI/MRCPPost-resection surveillance: Ultrasound and MRI/MRCP biannually (years 1–20); MRI/MRCP every 3 years (years 21–40) in lieu of ultrasound when indicated

ContextApplies to post-resection choledochal cyst surveillance and residual cystic tissue scenarios

Alternate schedulesIf ultrasound unavailable or not feasible, MRI/MRCP may be used on indicated schedule

MRI (T2*/non-contrast) — screening interval

Screening interval for MRI (T2*/non-contrast) in chronically transfused individualsScreening MRI every 12 months

Modality and techniqueT2* MRI (MRI Abdomen without contrast CPT 74181) for liver iron quantification; MRI Cardiac without contrast (CPT 75557) for cardiac iron

ContextAnnual screening for individuals at risk of transfusion-associated hemochromatosis

MRI or appropriate imaging — frequency every 3 months

Frequency for imaging during active treatment for iron overloadImaging every 3 months for individuals receiving active chelation and/or phlebotomy

ModalityAppropriate MRI (T2*/non-contrast) or other imaging as clinically indicated

PurposeMonitor treatment response during active therapy

Ultrasound — every 3-12 months

Ultrasound follow-up interval for hydronephrosisUltrasound every 3–12 months until resolution (postnatal follow-up)

Initial postnatal timingPostnatal ultrasound within 24 hours for males with distended bladder or moderate/severe antenatal hydronephrosis; after 7 days for mild prenatal hydronephrosis

Second postnatal scanSecond postnatal ultrasound at 4–6 weeks is medically necessary for all infants with antenatal hydronephrosis

Ultrasound (limited) — repeat as frequently as daily

Limited ultrasound repeat frequency (pyloric stenosis/intussusception)Repeat limited abdominal ultrasound as frequently as daily until diagnosis or resolution

Clinical scenarioUsed for infants with suspected hypertrophic pyloric stenosis when initial study nondiagnostic

DocumentationDocument clinical need for repeat daily studies when requested

Ultrasound (limited) — repeat as frequently as daily (duplicate)

Limited ultrasound repeat frequency (duplicate)Repeat limited abdominal ultrasound as frequently as daily until diagnosis or resolution

Applicable indicationsHypertrophic pyloric stenosis, serial assessments in infants

CodingReport limited ultrasound CPT 76705 as indicated per encounter

Prior Authorization — When to Expect It

Note

Contrast Use and Safety Considerations

Note

Not Covered / Exclusions

Unbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported and may be denied. In addition, PET/MRI is generally not supported for routine use except where explicitly allowed by condition‑specific PET/MRI criteria or when PET/CT is clinically indicated but unavailable; approved PET/MRI should be reported using the PET whole‑body CPT plus the appropriate unlisted MRI code.

CPT codes for 3D rendering (76376, 76377) should not be billed in conjunction with certain listed modalities and procedures (for example, CAD, MRA, CTA, nuclear medicine SPECT, PET/PET‑CT, stereotactic localization codes). These code combinations are explicitly disallowed by the guideline and may be subject to denial or audit.

Whole‑body CT screening (so‑called LifeScan or CT Brain/Chest/Abdomen/Pelvis screening) for asymptomatic individuals is not a covered benefit and is specifically excluded by the guideline.

Whole‑body CT screening for asymptomatic individuals is not a covered benefit and requests for such screening may be denied.

Use of advanced imaging modalities (CT, MRI, PET) to screen asymptomatic individuals for abdominal disorders is not supported unless a specific guideline section explicitly states otherwise. Advanced imaging should be reserved for individuals with documented signs, symptoms, or guideline‑supported indications.

Routine CT is not indicated for evaluation of an uncomplicated urinary tract infection. CT may have a role in diagnosing complications (e.g., renal abscess) but is not medically necessary for routine UTI evaluation.

Advanced imaging for uncomplicated pediatric acute gastroenteritis is not medically necessary unless there is concern for an alternative diagnosis or the presence of abdominal red flag symptoms that would justify CT/MR per the General Guidelines.

Imaging is not considered medically necessary for individuals with asymptomatic microscopic hematuria when proteinuria is absent. Ultrasound and other imaging are indicated when gross hematuria or microscopic hematuria with proteinuria is present, or when other clinical indications exist.

Background and Scope

These guidelines were developed to provide evidence‑based guidance for advanced imaging selection and utilization in pediatric abdominal conditions. They emphasize initial clinical evaluation, staged imaging (ultrasound first in most children), avoidance of unnecessary radiation, and documentation that imaging will impact patient management.

The guideline scope covers advanced imaging modalities commonly used in pediatric abdominal care — including ultrasound, CT, MRI, nuclear medicine, and PET — and applies evidence‑based recommendations to determine appropriate modality selection, contrast usage, and condition‑specific indications. It stresses that advanced imaging should follow a pertinent clinical evaluation and that investigational or experimental procedures (per the guideline definition) are not routinely supported.

Definitions and Terms

Investigational/Experimental definition

Definition — Investigational/ExperimentalProcedures, studies, or devices lacking sufficient supporting evidence, matured evidence of improved health outcomes, demonstrated clinical utility, or collective professional support are considered investigational/experimental

Evidence considerationsSupporting evidence includes peer‑reviewed literature and specialty society recommendations; lack thereof may render a study investigational

Policy implicationInvestigational or unproven studies may be denied during medical necessity review

Pediatric imaging applicability (age ≤18)

Pediatric applicability age cutoffApplies to individuals age ≤18 years — pediatric imaging guidelines used for imaging decisions when condition-specific pediatric guidance exists

AdultsIndividuals >18 years follow General Imaging Guidelines unless a specific guideline directs otherwise

ImplicationConfirm patient age to apply pediatric vs general imaging criteria

Concurrent supervision (3D rendering)

Concurrent supervision definition for 3D renderingActive physician participation and monitoring of the reconstruction process including design of anatomy to be reconstructed, tissue types to display, images/cine loops archived, and monitoring/adjustment of the 3D work product

Documentation recommendationACR recommends documenting the physician's supervision or participation in 3D reconstruction

Codes involvedApplies to CPT 76376 and CPT 76377 (3D rendering) where concurrent supervision is required

Stereotactic localization (CPT 77011) definition

Definition — Stereotactic localization (CPT 77011)A pre‑operative CT localization scan obtained for navigational workstations; typically a technical‑only service without radiologist interpretation unless diagnostic CT is performed

Billing guidanceDo not report both CPT 70486 and CPT 77011 for the same CT stereotactic localization session; if diagnostic CT interpreted, use appropriate diagnostic CT code instead of 77011

3D rendering note3D rendering codes should not be reported in conjunction with CPT 77011 because the procedure inherently generates a 3D dataset

SPECT/CT definition

SPECT/CT definitionSPECT/CT combines SPECT nuclear medicine imaging with CT to optimize localization, accuracy, and attenuation correction, providing functional and anatomic information

CPT examplesReported with CPT 78830–78832 for hybrid SPECT/CT; CPT 78072 for parathyroid SPECT/CT

Common usesUsed for MIBG, octreotide scintigraphy, and studies requiring combined functional/anatomic localization

Limited CT (CPT 76380) definition

Limited CT (CPT 76380) definitionA CT scan in which full diagnostic code work is not performed; used for limited or follow‑up slices (e.g., limited sinus CT, follow-up pulmonary nodule slices)

Not for treatment planningCPT 76380 is not medically necessary for treatment planning purposes and should not be used to cover extra slices in conjunction with diagnostic CT codes

No slice count specifiedAMA CPT does not define minimum or maximum number of sequences/slices for CT codes

Chronic abdominal pain definition

Chronic abdominal pain definitionAbdominal pain lasting over 2 months in children and adolescents

Functional abdominal pain disordersConditions with symptoms without structural or organic disease (includes functional dyspepsia)

Clinical implicationMost chronic abdominal pain does not require advanced imaging unless red flags or objective findings present

Functional abdominal pain disorders definition

Functional abdominal pain disorders definitionSymptom complexes without structural or organic disease, such as functional dyspepsia

Imaging implicationImaging generally not indicated for uncomplicated functional disorders absent red flags

Age contextApplies to children and adolescents per pediatric guidelines

Red flag findings definition

Red flag findings definitionClinical signs or symptoms identified in General Guidelines (PEDAB‑1.0) that necessitate advanced imaging and preclude adjudication by other criteria

ExamplesFever >100.4°F, peritoneal signs, GI bleeding, unexplained weight loss, jaundice, persistent high‑grade vomiting, history of malignancy, abnormal labs (e.g., high WBC or very low ANC)

Effect on pathwayPresence of any red flag directs to higher‑acuity imaging (e.g., CT with contrast) regardless of other rules

Enterography definition

Enterography definitionAdvanced cross‑sectional imaging of the small bowel to evaluate IBD; includes MR Enterography (preferred in children) and CT Enterography

IndicationsAssess disease severity/distribution, complications (fistula/abscess), and monitoring in Crohn disease

Associated CPTsMR Enterography commonly CPT 74183 (MRI abdomen without and with contrast) with pelvic MRI codes as needed

Pediatric BP staging and thresholds

Pediatric BP staging and thresholds overviewNormal BP <90th percentile (children ≥13 yrs: <120/<80); staged thresholds defined relative to percentiles with Stage 1 and Stage 2 definitions per guidelines

Diagnosis processDiagnosis requires auscultatory‑confirmed BP ≥95th percentile at 3 different visits

Use in imaging decisionsRepeated elevated readings support workup for secondary causes and imaging as indicated

Transient Elastography / VCTE definition

Transient Elastography / VCTE definitionVibration‑Controlled Transient Elastography (VCTE, e.g., Fibroscan) used for noninvasive staging of liver fibrosis (CPT 91200)

Role in pathwayInitial staging modality for suspected chronic liver disease; MRE used if TE fails or BMI ≥30

CodingTransient elastography CPT 91200; MRE CPT 76391

Transfusion-associated hemochromatosis definition

Transfusion‑associated hemochromatosis definitionIron overload resulting from repeated red blood cell transfusions, commonly after >20 transfusion episodes

Populations at riskCommon in sickle cell disease, thalassemia, bone marrow failure, oncology, and transplant patients

Imaging implicationTriggers regular T2* MRI screening and monitoring per guideline intervals

Antenatal hydronephrosis definition

Antenatal hydronephrosis (AHN) definitionPrenatal dilation of the fetal renal collecting system detected on ultrasound, stratified as mild/moderate/severe guiding postnatal timing and follow‑up

Postnatal imaging guidancePostnatal ultrasound timing and follow‑up depend on AHN severity (immediate for some, after 7 days for mild), with second scan at 4–6 weeks

Follow-up intervalsSubsequent ultrasound every 3–12 months until resolution is guideline‑supported

Intussusception definition

Intussusception definitionTelescoping of one bowel loop into another; frequent cause of abdominal pain in young children and may be associated with bloody stool

Initial imagingUltrasound is the medically necessary initial study when strong clinical suspicion exists

Secondary imagingCT with contrast indicated to characterize pathologic lead points identified on ultrasound

ADPKD definition

Autosomal dominant polycystic kidney disease (ADPKD) definitionHereditary cystic kidney disease; abdominal ultrasound appropriate for clinical concern or screening in at‑risk individuals

MRI limitation in young childrenMRI‑based diagnostic criteria are not established for children <15 years; MRI indications limited in this group

Imaging modalityUltrasound is primary screening modality in pediatric ADPKD

Bilious vomiting definition

Bilious vomiting definitionVomiting that suggests obstruction distal to the Sphincter of Oddi and may indicate emergencies like malrotation with midgut volvulus

Clinical urgencySuspected malrotation with bilious vomiting requires emergent imaging

Initial modalityLimited abdominal ultrasound (CPT 76705) is medically necessary for suspected malrotation/volvulus

Hypertrophic pyloric stenosis definition

Hypertrophic pyloric stenosis definitionIdiopathic thickening of the gastric outlet circular muscle causing projectile non‑bilious vomiting, typically in male infants aged 2–6 weeks

Initial imagingLimited abdominal ultrasound (CPT 76705) is medically necessary for infants with persistent projectile non‑bilious vomiting

Repeat imagingIf initial studies nondiagnostic, repeat limited US as frequently as daily until diagnosis or resolution

Revision History

2026-02-03policy_effectiveLatest

Policy version V1.0.2026 became effective (Pediatric Abdomen Imaging Guidelines; Guideline Number CSRAD015OH.E).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPediatric Abdomen Imaging Guidelines (Ohio)

Policy CodePolicy CSRAD015OH.E

Change TypeNo material changes

Effective DateFeb 3, 2026

Next Review DateN/A

Key ActionObtain and document a recent clinical evaluation (history, exam, labs, prior imaging) before ordering advanced pediatric abdominal imaging; use ultrasound as first-line when appropriate.

SourceLink

On This Page

Perianal disease: MRI Pelvis with contrast (CPT 72196) or MRI Pelvis without and with contrast (CPT 72197) is medically necessary when concern exists for perianal fistula or abscess.

Ultrasound (CPT 76700) is medically necessary as the initial imaging study for children with an intra-abdominal mass; ultrasound with Doppler (CPT 93975) is medically necessary to evaluate vascular supply.

Further imaging guided by ultrasound findings and other clinical data; oncology-specific follow-up as needed.

specific severe clinical features listed

Detailed indications in source guidance.

Specific lesion surveillance - hepatic adenoma: CT Abdomen (74160/74170) or MRI Abdomen (74183) every 6 months for 2 years, then annually for surveillance of hepatic adenoma to assess growth and malignant transformation.

Hepatic hemangioma follow-up: Limited ultrasound in 6-12 months; if stable/decreasing, surveillance 6-12 months until 2 years then no further follow-up unless symptomatic; if increasing, follow-up 3-6 months or biopsy.

FNH evaluation and follow-up: MRI (74183) or CT (74160/74170) to confirm FNH (Eovist-enhanced MRI often diagnostic); limited US in 6-12 months for follow-up; adolescent females on OCPs may require annual US for 2-3 years; CT/MRI if lesion not well visualized on US or increasing in size; follow-up 3-6 months or biopsy if increasing.

Nuclear medicine liver imaging indications: Nuclear liver imaging (one of CPT 78201/78202/78803/78215/78216) is medically necessary when US/CT/MRI are unavailable or contraindicated for evaluation of liver mass, trauma, suspected FNH, differentiation of hemangioma from FNH, diffuse hepatic disease, elevated LFTs, or suspected accessory spleen.

Choledochal cyst: If choledochal cyst is suspected: CT Abdomen with contrast (74160) or MRI/MRCP (74183/74181) is medically necessary; MRI/MRCP is preferred for preoperative assessment.

Post-resection surveillance - years 1-20: After resection of choledochal cyst types I, IV, and unreplaced type V: ultrasound biannually and MRI/MRCP (74183) every 3 years (in lieu of US) when US not feasible.

Post-resection surveillance - years 21-40: Ultrasound every 3 years; MRI/MRCP every 4 years (in lieu of ultrasound) when US not feasible.

Obstructive uropathy pre/post-op: In obstructive uropathy, retroperitoneal ultrasound (CPT 76770) and diuretic renography (CPT 78707–78709) are medically necessary for preoperative planning and postoperatively at 3–12 months; if hydronephrosis resolved on postoperative imaging no further routine imaging is indicated.postop interval=3-12 months

Inconclusive ultrasound: MR urography (MRU CPT 74183 and CPT 72197) is medically necessary when ultrasound and diuretic renography are inconclusive; CT Abdomen with contrast (CPT 74160) is medically necessary when ultrasound is inconclusive and a vascular cause of UPJO is suspected.

CT for complications: CT Abdomen and Pelvis with contrast (CPT 74177) is medically necessary for evaluation of known or suspected complications of acute pancreatitis and to characterize collections prior to intervention.

CT indicated for complication assessment and procedural planning.