Ohio-only prior authorization & medical necessity review

This guideline applies only in Ohio; imaging requests inconsistent with the guideline (including investigational or research/data-collection imaging) will be reviewed for medical necessity per Ohio Administrative Code 5160-1-01 and plan prior authorization processes.

CPT listing is not authorization

Inclusion of a CPT code in these guidelines does not mean the code requires prior authorization; providers must verify separate management or prior authorization requirements with the plan.

3D rendering (CPT 76376/76377) may require PA

Prior authorization may be required for 3D rendering codes (CPT 76376, 76377) even when authorization is not required for the base imaging study; obtain prior authorization per plan when applicable.

• Do not report 3D rendering codes for routine 2D reformatting; document physician supervision/participation in reconstruction when billing.

SPECT/CT reporting and PA management

Report hybrid SPECT/CT nuclear studies using the appropriate CPT codes (78830, 78831, 78832); CPT 78072 applies for SPECT/CT parathyroid imaging and prior authorization is managed per the applicable guideline sections.

• Use CPT 78830/78831/78832 for hybrid nuclear/CT reporting.
• Use CPT 78072 for SPECT/CT parathyroid imaging where applicable.

PET/MRI authorization conditions (report as 78813 + 76498)

PET/MRI is generally not medically necessary but may be authorized when PET/CT criteria are met and PET/CT is unavailable and the provider requests PET/MRI; when authorized report PET/MRI as CPT 78813 plus CPT 76498.

• Documentation must show PET/CT criteria were met and PET/CT was not available at the treating institution when substituting PET/MRI.

Clinical evaluation required; justify MRI contrast (CPT 74183)

Advanced imaging (CT, MR, Nuclear Medicine) should be preceded by a pertinent clinical evaluation (history, physical, appropriate labs, prior imaging); MRI abdomen is generally performed without and with contrast (CPT 74183) and use of contrast must be justified.

• A meaningful technological contact (telehealth, telephone, messaging) may satisfy the clinical evaluation in some cases.
• If IV contrast is proposed for MRI (74183), document contraindications and necessity per section guidance.

Ultrasound first; CT/MRI only per criteria

Abdominal ultrasound (CPT 76700/76705) is the medically necessary initial imaging for children without red flags; CT (CPT 74160/74177) or MRI (CPT 74181/74183 and 72195/72197) are medically necessary only when red flags or specified criteria are met.

• Obtain ultrasound results prior to authorizing CT or MRI except when red flags are present.
• CT/MRI authorization expected when ultrasound is inconclusive, BMI ≥85th percentile, insufficient local US expertise, or complication suspected.

Staged imaging: ultrasound → CT → MRI/nuclear as indicated

Follow modality-step requirements: initial ultrasound, then CT if ultrasound is inconclusive, with MRI or nuclear studies reserved for specific further indications; order studies in a staged fashion per the guideline.

• For flank pain: ultrasound (76770/76775) → CT without contrast (74176) if inconclusive → MRI (74183/72197) if CT inconclusive or to reduce radiation exposure.

Enterography (MRE/CTE) required when IBD criteria met

MR Enterography or CT Enterography (or MRI abdomen/pelvis with and without contrast) is medically necessary for suspected Crohn disease or when clinical/lab/endoscopic criteria (e.g., positive family history, suggestive endoscopy, or elevated inflammatory markers) are present; prior authorization may be required.

• Elevated inflammatory markers thresholds: fecal lactoferrin ≥4.0 µg/g, CRP >0.5 mg/dL, fecal calprotectin ≥50 µg/g.
• Enterography may be performed prior to endoscopy if requested by the endoscopist.

Document indications when requesting enterography or MRI Abdomen/Pelvis

When enterography or MRI abdomen/pelvis with and without contrast is requested, document the clinical scenario meeting listed indications (e.g., suspected Crohn disease, positive family history, endoscopy findings, or elevated inflammatory markers) to support authorization.

• Provide endoscopy/colonoscopy findings or inflammatory marker results when available.

Authorization expectation for listed CPT studies

Specific CPT-coded CT, MRI, PET, and nuclear studies listed in the guideline are identified as medically necessary for pediatric indications but may still require prior authorization per payer processes; follow the listed CPTs and indications when requesting authorization.

• Providers should request the listed study appropriate to clinical context to streamline authorization.

Ultrasound with duplex first for pediatric liver indications

For pediatric liver disease, ultrasound with duplex Doppler (CPT 76700 + 93975) is medically necessary as the initial study prior to approving CT or MRI; MRI is preferred over CT when feasible to reduce radiation exposure.

• Document ultrasound/duplex findings before requesting CT/MRI authorization.

PA expectations for MRE and MRI iron quantification

Prior authorization is expected for MRE (CPT 76391) and MRI iron quantification studies when higher-resource modalities are requested: MRE is medically necessary only after transient elastography failure (despite XL-probe), BMI ≥30, or conflicting results; T2* MRI for iron quantification requires scheduling per surveillance intervals.

• Screening MRI for chronically transfused individuals: every 12 months; during active treatment, imaging every 3 months.

Align PA requests with listed CPT codes and indications

When requesting authorization, follow the guideline’s listed CPT codes and indications for the specific pediatric condition to justify medical necessity (e.g., MRI Abdomen 74183 for lesion characterization, CT 74177 for red-flag abdominal symptoms).

• Use the CPTs enumerated in the condition-specific sections to align requests with policy criteria.

PA for specialty pediatric abdominal studies

Certain specialty pediatric abdominal studies (e.g., MRI abdomen/pelvis, CT abdomen/pelvis, nuclear spleen imaging) are medically necessary for specified indications and may require payer prior authorization; follow the condition-specific criteria and local PA processes.

• When MRI is the preferred modality (e.g., spleen, bowel obstruction) ensure documentation supports why MRI is indicated and check local PA rules.

Clinical evaluation required before advanced imaging

Advanced imaging should not be ordered prior to clinical evaluation by the treating physician or appropriate consultant; a meaningful technological contact (telehealth/phone/email) since onset/change may satisfy this requirement in some cases.

• Exceptions apply for guideline-supported scheduled surveillance imaging.

Maintain conservative therapy if improving before advanced imaging

Continue conservative therapy prior to ordering advanced imaging when the individual is clinically improving; avoid advanced imaging solely to document improvement.

• Document clinical course showing lack of need for escalation while conservative measures continue.

Staged imaging: ultrasound first, escalate per criteria

Use a staged imaging strategy: perform ultrasound first (except when red flags present), then proceed to CT or MRI only if ultrasound is non-diagnostic, the patient is overweight (BMI ≥85th percentile), local ultrasound expertise is insufficient, or complication is suspected.

• BMI ≥85th percentile is a stated threshold for escalation to CT/MRI in appendicitis workup.

Flank pain/renal stone: US → CT (74176) if US inconclusive

For renal stone evaluation in children, ultrasound (CPT 76770/76775) is the initial study; if ultrasound is inconclusive, CT without contrast (CPT 74176) is medically necessary as the next step.

• If CT is inconclusive or radiation exposure is a concern, consider MRI (CPT 74183) and pelvis MRI (72197) as appropriate.

Imaging for postoperative complications within 60 days

For suspected postoperative complications within 60 days (e.g., abscess, obstruction), CT, MRI, or nuclear medicine studies listed in the guideline are medically necessary; MRI may substitute for CT only if it can be completed in a similar time frame.

• CT Abdomen and Pelvis with contrast (CPT 74177), MRI Abdomen and Pelvis (CPT 74183/72197 or 74181/72195), and relevant nuclear medicine CPTs are options.

Abdominal wall mass: US or MRI first; CT only if inconclusive

For a newly discovered abdominal wall mass, ultrasound or MRI are first-line imaging; CT is medically necessary only if ultrasound and/or MRI are inconclusive or insufficient for preoperative planning.

• If below the umbilicus add pelvic MRI (CPT 72195/72197) as indicated.

Pediatric liver/biliary imaging: duplex US first-line before CT/MRI

For pediatric liver/biliary indications, ultrasound with duplex Doppler (CPT 76700 + 93975) is required as the initial study prior to CT or MRI authorization; MRI (74183) is preferred over CT when feasible to reduce radiation.

• Repeat ultrasound annually for known chronic liver dysfunction or sooner for clinical/lab changes.

Elastography sequence: VCTE (91200) before MRE (76391)

Transient elastography/VCTE (CPT 91200) is the recommended initial modality for liver fibrosis staging; MRE (CPT 76391) is medically necessary only after VCTE failure despite XL-probe, BMI ≥30, or conflicting results.

• Document VCTE failure, XL-probe inability, BMI ≥30, or discordant results when requesting MRE.

Intussusception: ultrasound first; CT/MRI for lead points

Ultrasound is required as the initial study for suspected intussusception; cross-sectional imaging (CT/MRI) is reserved to characterize pathologic lead points identified on ultrasound.

• CT Abdomen and/or Pelvis with contrast (74160 or 74177) is medically necessary to evaluate identified lead points.

Medical necessity adjudication per Ohio Administrative Code 5160-1-01

Medical necessity will be evaluated under Ohio Administrative Code 5160-1-01; documentation must demonstrate clinical utility and adherence to guideline criteria to support approval.

• Requests inconsistent with guideline or investigational indications will be reviewed and may be denied.

Required clinical documentation (history, exam, labs, prior imaging)

Include pertinent clinical evaluation since onset or change in symptoms (detailed history, physical exam), relevant laboratory studies, and prior imaging when requesting advanced imaging to support medical necessity.

• Labs to include as relevant: CBC, electrolytes, lipase/amylase, urinalysis, ESR/CRP, LFTs, stool studies.
• Obtain and document prior imaging results before requesting further studies when possible.

Document prior imaging review and rationale for new study

Review prior imaging and include a clinical history demonstrating how the requested imaging will affect management; for stereotactic CT localization (77011) document the technical-only nature if billing 77011 instead of a diagnostic CT code.

• If a diagnostic CT is performed and interpreted, report the diagnostic CT code (e.g., 70486) rather than 77011.

Documentation requirements for unlisted and localization scans (76497/76498/77011)

When billing unlisted CT/MR procedures (CPT 76497/76498) or stereotactic localization (77011), document the clinical scenario and rationale (e.g., navigation/planning, thinner cuts, positional acquisition) and provide a Category III code if available.

• Retain documentation of why an anatomic site-specific CPT does not apply and include procedural details to justify the unlisted code.

PET/MRI substitution: documentation of PET/CT criteria & unavailability

When PET/MRI is used instead of PET/CT, document that PET/CT criteria were met and PET/CT was unavailable at the treating institution and that the provider requested PET/MRI; report PET/MRI as CPT 78813 + 76498 when authorized.

• Include evidence that the individual meets condition-specific PET/CT criteria when substituting PET/MRI.

Required clinical evaluation before authorization

Prior clinical evaluation is required prior to advanced imaging; include history, labs, basic imaging or technological contact to support the request unless the imaging is a guideline-supported scheduled study.

Clinical and laboratory documentation to include with imaging requests

When requesting advanced imaging, include pertinent labs and exams as relevant (examples: CBC, electrolytes, lipase, amylase, urinalysis, ESR, CRP, LFTs, stool testing) to support medical necessity.

• Provide ultrasound findings when ordering CT or MRI that follow an ultrasound-first pathway.

Document red flag assessment (PEDAB-1.0)

Document assessment for red flags per the General Guidelines (PEDAB-1.0); presence of any red flag findings precludes adjudication based on other criteria and supports advanced imaging.

• Red flags include fever >100.4°F, GI bleeding, peritoneal signs, abnormal WBC, jaundice, abdominal mass, failure to thrive, among others.

Required documentation for enterography (family history, endoscopy, inflammatory markers)

For enterography requests, include family history, endoscopy/colonoscopy findings, or elevated inflammatory markers (fecal lactoferrin ≥4.0 µg/g, CRP >0.5 mg/dL, fecal calprotectin ≥50 µg/g) in the documentation to support medical necessity.

• Provide colonoscopy/endoscopy reports when available or note that enterography was requested by the endoscopist.

Denial risk for investigational, research, or non-standard imaging

Imaging requests that are experimental, investigational, unproven, inconsistent with established clinical standards, or requested for data collection rather than direct clinical management may be denied as not medically necessary.

• Clinical trial–only imaging or imaging performed primarily for research/data collection is subject to denial.

Denial risk: PET unbundling, PET/MRI, surveillance PET

Unbundling PET/CT into separate PET and diagnostic CT CPT codes, PET/MRI generally, and surveillance PET (unless condition-specific) are not medically necessary and may be denied.

• Do not bill PET and diagnostic CT separately for a PET/CT study; request combined PET/CT as indicated.

Whole-body CT/LifeScan screening is not covered

Whole-body CT or LifeScan for screening asymptomatic individuals is not a covered benefit and requests for such screening will be denied.

Appropriateness requirement: imaging must affect management

Advanced imaging is not indicated when the results will not affect individual management decisions; repeat imaging of the same body area requires evidence of progression, new disease, or documentation that the repeat study will affect management.

• Provide documentation showing how repeat imaging will change treatment or management to avoid denial.

Denial risk if red flags not documented

Failure to document red flag signs or symptoms when present may lead to inappropriate use of ultrasound when advanced imaging is indicated and could result in denial or delayed authorization.

• If red flags exist, document them clearly to support escalation to CT/MRI without prior ultrasound.

Red flag findings preclude other criteria

Presence of any red flag findings per General Guidelines (PEDAB-1.0) precludes adjudication based on other criteria and requires consideration of advanced imaging or urgent evaluation.

Initial ultrasound prerequisite before CT/MRI; MRI preferred

CT or MRI approval is expected only after initial ultrasound in pediatric individuals; MRI is preferred when possible to reduce radiation exposure—document why CT is necessary if MRI is available.

• Ultrasound with duplex Doppler is required prior to CT/MRI for many liver/biliary indications.

MRE use conditional — document VCTE failure/BMI ≥30/discordant results

MRE is indicated only after failure of transient elastography (despite XL-probe), BMI ≥30, or when results conflict with the clinical picture; failure to document these conditions may risk denial.

Hemochromatosis MRI scheduling expectations (12 mo / 3 mo during treatment)

Schedule MRI for iron quantification per guideline intervals: screening MRI every 12 months for chronically transfused individuals; imaging every 3 months for treatment response during active chelation/phlebotomy; requests outside these intervals may be denied.

• T2* MRI techniques do not require contrast (use CPT 74181, 75557, or 71550 as applicable).