Prior authorization applicability — check Cigna CPT list

These guidelines include procedures that eviCore does and does not review for Cigna; providers must refer to the Cigna CPT code list for the current list of high‑tech imaging procedures that eviCore reviews for Cigna.

No prior authorization rules specified in TOC excerpt

The table of contents portion of this excerpt does not state prior authorization requirements; full prior authorization rules are located in the complete policy and payer-specific processes.

Prior authorization expectation for MRI/CT modalities

Prior authorization for advanced abdominal MRI/CT should follow the payer's rules; MRI abdomen is generally performed without and with contrast (CPT 74183) and CT abdomen/pelvis codes (e.g., CPT 74160, 74177) are referenced as condition-specific advanced imaging options.

Advanced imaging only after ultrasound or when conditions met

CT or MRI are appropriate only after ultrasound is inconclusive or when specified conditions exist (BMI ≥85th percentile, insufficient local ultrasound expertise, concern for complication); payer prior authorization may be required per policy for these advanced studies.

• Ultrasound should be initial imaging in most children prior to advanced imaging (chunk 179).
• Advanced imaging indicated when US inconclusive, BMI ≥85th percentile, insufficient US expertise, or complication suspected (chunk 208).

Prior authorization expectation for advanced pediatric abdominal studies

Certain advanced pediatric abdominal studies (e.g., CT, MRU, diuretic renography, DMSA, VCUG/radionuclide cystography) are described as medically necessary only for listed indications; documentation of indication is required when these studies are ordered.

• MRU (CPT 74183/72197) is not first‑line but medically necessary for investigation of a dilated upper urinary tract (chunk 220).
• Diuretic renography (CPT 78707/78708/78709) and DMSA (CPT 78700/78701/78803) have specific indications (chunk 219, 220).
• VCUG/radionuclide cystography (CPT 78740) is specified for reflux evaluation (chunk 219).

Submit CPT-coded imaging and clinical indication

When requesting imaging for pediatric abdominal indications, submit the specific CPT-coded study along with the clinical indication described in the guideline to support medical necessity.

• Providers should include the CPT code and supporting clinical details per the condition-specific guidance (e.g., hydronephrosis, recurrent febrile UTI, hematuria type) (chunks 234, 242).

Documentation required for listed CPT studies when seeking authorization

Imaging studies listed as medically necessary (CT, MRI, Ultrasound CPT codes in the guideline) require documentation of the indications described in the guideline (e.g., suspected postoperative complications, red flag symptoms, or characterization needs) when authorization is sought.

• Orders should reference postoperative timing (within 60 days), red flag signs/symptoms, or mass characterization needs as applicable (chunks 254, 264, 266).

Continue conservative management before advanced imaging

Continue conservative therapy prior to advanced imaging when the individual is improving on current treatment programs; advanced imaging is intended to answer clinical questions that will affect management.

• Imaging is not indicated if results will not affect individual management decisions (chunk 179).

Ultrasound-first for generalized abdominal pain (CT only with red flags)

For generalized abdominal pain without red flag signs or symptoms, ultrasound (CPT 76700 or 76705) is medically necessary as the initial imaging prior to CT.

• CT (CPT 74160 or 74177) is indicated only if red flag signs/symptoms are present (chunk 195).

Imaging step sequence — ultrasound first, then CT/MRI as indicated

Follow an imaging step sequence: ultrasound is the medically necessary initial modality for most pediatric abdominal pain presentations; CT or MRI are appropriate subsequent steps when ultrasound is inconclusive or other conditions exist.

• Ultrasound should be done prior to advanced imaging in most children (chunk 179).
• CT or MRI are medically necessary if ultrasound is inconclusive, BMI threshold met, insufficient local US expertise, or complication suspected (chunks 208, 215).

Ultrasound-first workflow for first-time pediatric UTI; follow-up per US findings

For first‑time pediatric UTI, ultrasound is the initial required study; follow-up testing (VCUG, radionuclide cystography, CeVUS) is guided by ultrasound findings and clinical context.

• Ultrasound (CPT 76770/76775) is medically necessary as the initial imaging for first‑time upper urinary tract infection (chunk 219).
• VCUG (fluoroscopic) or radionuclide cystography (CPT 78740) and CeVUS are appropriate for reflux evaluation per guidelines (chunks 219, 222).

RUQ pain — US or HIDA first; MRI/CT if equivocal

For suspected RUQ biliary pathology, ultrasound (CPT 76700) or HIDA (CPT 78226/78227) is the initial approach; MRI (CPT 74183) or CT (CPT 74160) are medically necessary when ultrasound or HIDA are equivocal.

• Ultrasound results are not required prior to HIDA (chunk 238).

Modality sequencing for intra‑abdominal mass — ultrasound required first

For an intra‑abdominal mass, ultrasound (CPT 76700) is the required initial study; add Doppler (CPT 93975) to assess vascularity and proceed to CT/MRI based on ultrasound results and clinical context.

• Additional imaging determined by ultrasound findings, location, organ involvement, history, exam, and labs (chunk 266).

Reference member benefit plan and laws for coverage decisions

Providers must reference the member's specific benefit plan document and applicable laws/regulations when requesting coverage; the coverage policy is guidance used by medical directors for medical necessity determinations.

Required prior clinical evaluation before advanced imaging

A pertinent clinical evaluation (history, physical, appropriate labs, and basic imaging) should be performed prior to advanced imaging requests unless guideline‑supported scheduling or red flags exist.

• A meaningful technological contact (telehealth, phone, electronic messaging) can serve as the pertinent clinical evaluation (chunk 179).

Document red flag presence/absence — impacts adjudication

Document the presence or absence of red flag findings (e.g., fever >100.4°F, GI bleeding, guarding/rebound, abnormal WBC including ANC <1000, abdominal mass) because red flags preclude standard adjudication and may necessitate advanced imaging.

• Red flag presence removes requirement for initial ultrasound and triggers a different adjudication pathway (chunk 180).
• Any red flag per General Guidelines precludes adjudication based on other criteria (chunk 208).

Required documentation elements to justify advanced imaging

Include ultrasound results, BMI percentile when relevant, laboratory data, and clinical exam findings to support the need for advanced imaging and modality selection.

• If appendix not visualized on ultrasound and WBC not elevated, often no further imaging is necessary — document ultrasound and WBC (chunk 208).
• Preliminary labs may include CBC, electrolytes, lipase, amylase, urinalysis, ESR, CRP, LFTs as applicable (chunk 195).

Document clinical indication and ultrasound findings for urinary/hematuria imaging

Document clinical indication and relevant ultrasound findings (e.g., hydronephrosis, atypical or recurrent febrile UTI, hematuria type) when requesting modality‑specific studies like VCUG, MAG3, DMSA, CT, or MRU.

• Examples: hydronephrosis prompting VCUG; atypical/recurrent febrile UTI prompting DMSA or MAG3; hematuria type dictating US vs CT selection (chunks 219, 234).

Document inflammatory markers to support enterography for suspected IBD

Elevated inflammatory markers (fecal lactoferrin ≥4.0 µg/g, CRP >0.5 mg/dL, or fecal calprotectin ≥50 µg/g) support medical necessity for MR or CT enterography when Crohn disease is suspected.

• Enterography (MR or CT) is medically necessary when inflammatory markers meet listed thresholds or other listed criteria (chunk 243).

Include postoperative timing and indication for post‑op imaging requests

Orders for postoperative imaging should state the clinical indication and note postoperative timing (within 60 days) to justify CT/MRI/US studies for suspected complications.

• CT Abdomen and Pelvis with contrast (CPT 74177), Ultrasound (CPT 76700/76705), or MRI (CPT 74183/72197 or CPT 74181/72195) are listed as medically necessary within 60 days post‑op (chunk 254).

Determinants of coverage decisions — check plan and laws

Coverage determinations consider the member's benefit plan terms, applicable laws/regulations, collateral materials, and case facts; the benefit plan document supersedes the coverage policy when conflicting.

Service coverage scope — managed CPT codes may require authorization

These guidelines apply to services and supplies managed by eviCore for Cigna as outlined by the Cigna CPT list; procedures outside the listed CPTs may not be supported and could lead to denial.

• Refer to the Cigna CPT list for which high‑tech imaging procedures eviCore reviews for Cigna (chunk 1).
• Procedure codes managed under these guidelines are listed in the procedure code table (chunk 175).

Denial risk: CT ordered before recommended ultrasound (no red flags)

Ordering CT abdomen for generalized abdominal pain when ultrasound is the recommended initial study and no red flags are present could lead to denial.

• Ultrasound (CPT 76700/76705) is the medically necessary initial imaging for children without red flags (chunk 195).

Red flags preclude standard adjudication — document and act accordingly

Presence of any red flag findings per General Guidelines precludes adjudication based on other criteria and triggers a different pathway for imaging decisions (may necessitate advanced imaging).

• Red flags include unexplained fever >100.4°F, GI bleeding, guarding/rebound, abnormal WBC including ANC <1000, abdominal mass, failure to thrive, jaundice, and others listed (chunk 180).