UnitedHealthcare Adult Abdomen Imaging Policy Update

Coverage summary and scope

This guideline is an Ohio-only adult abdomen imaging guideline (UnitedHealthcare Adult Abdomen Imaging Guidelines, CSRADOOIOH.D) effective 2025-11-01; it provides evidence‑based, proprietary recommendations to guide modality selection and reduce overuse of advanced imaging while allowing physician judgment, and is reviewed on an annual basis.

Key jurisdictional and threshold items

jurisdictionOhio-only

effective_date2025-11-01

clinical_evaluation_recencywithin 60 days

unit_per_encounter_rule1 for guidance codes (77012/77021/77013/77022/76942, etc.)

category_III_codes_investigational6 (listed Category III MR quantitative analysis codes: 0648T, 0649T, 0697T, 0698T, 0865T, 0866T)

red_flag_definitionUse 'Red flag findings' from definitions: includes fever >=101°F; history of malignancy with propensity to metastasize to abdomen; elevated WBC >10,000 or above lab ULN; palpable mass without benign features; ANC <1000; GI bleeding not obviously hemorrhoidal; moderate/severe abdominal tenderness; peritoneal signs (guarding/rebound); provider notation of 'surgical abdomen'; suspected complication of bariatric surgery; age >=60 with unintentional weight loss >=10 lbs or >=25% body weight over 6 months

Medical-necessity criteria (condition-based trees)

Application / General Requirements

ALL of the following

This set of general requirements applies to all advanced abdominal imaging requests unless a condition-specific 'red flag' exclusion (see Red Flag exclusion) is present.
A recent clinical evaluation (in-person visit OR meaningful technological contact such as telehealth, telephone, secure electronic message) documenting the current problem, onset or change in symptoms, and relevant exam findings must be available within 60 days prior to the requested advanced imaging unless the request meets a Red Flag exclusion or is a guideline-supported scheduled surveillance study.
Pertinent prior studies and results (plain radiographs, prior CT/MRI/US, laboratory data relevant to the clinical question) should be provided and referenced in the request when available.
Imaging should be directed to answer a specific clinical question; requests that are purely for screening without indication should follow Screening/Surveillance guidance in condition-specific sections.

Coding tables and status groups

Guidance / Procedural CPT codes referencedCPT

76376	3D rendering without independent workstation
76377	3D rendering requiring independent workstation
19085	Biopsy, breast; percutaneous; first lesion, including MR guidance
19086	Biopsy, breast; percutaneous; each additional lesion, including MR guidance
75989	Imaging guidance for percutaneous drainage with placement of catheter
76942	Ultrasonic guidance for needle placement
77011	CT guidance for stereotactic localization
77012	CT guidance for needle placement
77013	CT guidance and monitoring of parenchymal tissue ablation
77021	MR guidance for needle placement

1–10 of 13

1/2

Guidance and imaging procedure CPT codes referencedCPTCovered

70486	Diagnostic CT (example referenced for diagnostic scan interpretation by radiologist)
76376	3D rendering not requiring image post-processing on independent workstation
76377	3D rendering requiring image post-processing on independent workstation
77011	Fluoroscopic guidance for needle placement (contextual reference)
77012	CT guidance for needle placement (percutaneous procedures)
77021	MR guidance for needle placement (percutaneous procedures)
19085	Breast biopsy, first lesion (appropriate for breast biopsy guidance instead of 77021)
19086	Breast biopsy, additional concurrent lesions
77013	CT guidance for ablation (non-bone ablation procedures)
77022	MR guidance for ablation

1–10 of 47

1/5

HCPCS / non-specific codes guidanceHCPCS

S8042

Low-field MRI (non-specific HCPCS example) — requests should be redirected to more appropriate CPT if applicable

CT Abdomen without contrastCPTCovered

74150	CT Abdomen without contrast (listed earlier)
74176	CT Abdomen and Pelvis without contrast (non-contrast for stones)

Guidance and imaging procedure CPT codes referencedCPTCovered

70486	Diagnostic CT (example referenced for diagnostic scan interpretation by radiologist)
76376	3D rendering not requiring image post-processing on independent workstation
76377	3D rendering requiring image post-processing on independent workstation
77011	Fluoroscopic guidance for needle placement (contextual reference)
77012	CT guidance for needle placement (percutaneous procedures)
77021	MR guidance for needle placement (percutaneous procedures)
19085	Breast biopsy, first lesion (appropriate for breast biopsy guidance instead of 77021)
19086	Breast biopsy, additional concurrent lesions
77013	CT guidance for ablation (non-bone ablation procedures)
77022	MR guidance for ablation

1–10 of 38

1/4

CT Abdomen without contrastCPTCovered

74150

CT Abdomen without contrast (listed earlier)

CT Abdomen with contrast / CT Abdomen and Pelvis with/without contrastCPTCovered

74160	CT Abdomen with contrast
74170	CT Abdomen without and with contrast (LUQ section references CPT 74170/74160 variants)
74177	CT Abdomen and Pelvis with contrast
74176	CT Abdomen and Pelvis without contrast (also referenced above)
74178	CT Urogram

Abdominal Ultrasound / Pelvic / TransvaginalCPTCovered

76700	Ultrasound, complete Abdomen
76705	Ultrasound, limited Abdomen
76830	Ultrasound, Transvaginal
76856	Ultrasound, complete Pelvis
76770	Retroperitoneal ultrasound
76775	Limited retroperitoneal ultrasound variant

MRI Abdomen / Pelvis / MRCPCPTCovered

74181	MRI Abdomen without contrast
74183	MRI Abdomen without and with contrast
72195	MRI Pelvis without contrast
72197	MRI Pelvis without and with contrast
74183	MRCP / MRI Abdomen with/without contrast (MRCP referenced as CPT 74181 or 74183)

Hepatobiliary (HIDA) scansCPTCovered

78226	HIDA without pharmacologic intervention
78227	HIDA with pharmacologic intervention

Ultrasound for follow-up / serial imagingCPTCovered

76705

Serial ultrasound (limited) for follow-up of fluid collections/abscess

CT Abdomen and Pelvis without contrastCPTCovered

74176

CT Abdomen and Pelvis without contrast

CT Abdomen and Pelvis with contrast / CT AbdomenCPTCovered

74177	CT Abdomen and Pelvis with contrast
74160	CT Abdomen

CT UrogramCPTCovered

74178

CT Abdomen and Pelvis without and with contrast (CT urogram)

Retroperitoneal/Abdominal UltrasoundCPTCovered

76770	Retroperitoneal ultrasound, single or limited
76775	Retroperitoneal ultrasound, complete
76700	Abdominal ultrasound, complete (for bariatric pre-op)
76705	Abdominal ultrasound, limited (for bariatric pre-op)

MRI Abdomen and PelvisCPTCovered

74181	MRI Abdomen and Pelvis without contrast
72195	MRI Pelvis without contrast
74185	MRA Abdomen
72198	MRA Pelvis

CT Angiography (Mesenteric / Abdomen)CPTCovered

74174	CTA Abdomen and Pelvis
74175	CTA Abdomen (mesenteric)
72191	CTA Pelvis (listed in context)

Mesenteric Duplex / Vascular UltrasoundCPTCovered

93975	Mesenteric artery duplex, duplex study
93976	Mesenteric artery duplex, complete

Nuclear Kidney Imaging / Renal ScintigraphyCPTCovered

78707	Renal cortical imaging, static (renal scintigraphy)
78708	Renal cortical imaging, multiple studies
78709	Renal imaging, functional studies

KUB / Plain X-rayCPTCovered

not specified

KUB plain radiography (referred to but exact CPT not listed in this part)

3-D ReconstructionCPTCovered

76376	3D rendering with CT
76377	3D rendering with CT, advanced visualization

PET/CTCPT

78815

PET/CT whole body (used to localize biopsy site prior nondiagnostic biopsy)

Post-operative CT / Other CT codesCPTCovered

72193

CT Pelvis with contrast (listed in post-op context)

CT Abdomen / Pelvis / Chest codes referencedCPTCovered

74177	CT Abdomen and Pelvis with contrast
74160	CT Abdomen with contrast
74150	CT Abdomen without contrast
74176	CT Abdomen and Pelvis without and with contrast / or with/without per text
72193	CT Pelvis with contrast
72192	CT Pelvis without contrast
71260	CT Chest with contrast
74170	CT Abdomen without and with contrast (adrenal protocol)

MRI Abdomen / Pelvis codes referencedCPTCovered

74181	MRI Abdomen without contrast (including chemical shift MRI)
74183	MRI Abdomen without and with contrast
72195	MRI Pelvis without contrast
72197	MRI Pelvis without and with contrast

Ultrasound codes referencedCPTCovered

76700	Abdominal ultrasound complete
76705	Abdominal limited ultrasound
76856	Pelvic ultrasound complete
76857	Pelvic ultrasound limited
76830	Transvaginal ultrasound

Other imaging / nuclear / PET codes referencedCPT

78815

PET/CT, Skull base to mid-thigh (listed among CPT descriptions)

CT Abdomen without and with contrast (adrenal protocol)CPTCovered

74170

CT Abdomen without and with contrast (adrenal protocol)

Nuclear medicine (MIBG / SPECT / PET / hybrid)CPTCovered

78801	Nuclear medicine imaging (MIBG) code - approved
78802	Nuclear medicine imaging (MIBG) code - approved
78803	SPECT study (may be approved with MIBG)
78804	Nuclear medicine imaging (MIBG) code - approved
78830	Hybrid SPECT/CT study (may be approved)
78831	SPECT study (alternative code)
78832	Hybrid SPECT/CT study (alternative code)
78075	Adrenal scintigraphy / planar adrenal imaging (NP-59, MIBG) - noted as insufficient for initial evaluation of suspected pheochromocytoma/paraganglioma
78815	PET, Skull Base to Mid-Thigh (listed in header)

PET/CTCPTCovered

78815

PET, Skull Base to Mid-Thigh / PET/CT (referenced in header)

CT Enterography / EnteroclysisCPTCovered

74177	CT Enterography (same CPT as CT Abdomen/Pelvis with contrast referenced for enterography)
74183	MR Enterography / MR Enteroclysis (MRI Abdomen/Pelvis codes used)

Gastric Emptying / Motility / GI NuclearCPTCovered

78264	Gastric Emptying Study (solid-phase) — indicated for gastroparesis features
78265	Gastric emptying study with small bowel transit
78266	Gastric emptying study with small bowel and colon transit
78290	Meckel's scan
78278	Gastrointestinal bleeding scintigraphy (tagged RBC)

Video Capsule EndoscopyCPTCovered

91110

Video capsule endoscopy (not explicitly listed in text but VCE referenced)

Investigational / Not CoveredCPTNot Covered

72195

MRI Pelvis without contrast for Defecography is considered investigational/experimental by UnitedHealthcare (note: same code appears in covered MRI list where used for other MRI pelvis entries)

CT Abdomen and Pelvis / CT Enterography / CT EnteroclysisCPTCovered

74176	CT Enteroclysis or CT Abdomen & Pelvis without contrast (as listed in text)
74177	CT Abdomen and Pelvis with contrast / CT Enterography (document lists CPTC 74177 / CPT 74177 interchangeably)

MR Enterography / MRI Abdomen / MRCP / MRI PelvisCPTCovered

74181	MRI Abdomen (listed as CPT 74181 in some cross-references)
74183	MRI Abdomen (enterography) / CT/MR enterography code referenced as CPT 74183
72197	MRI Pelvis without and with contrast
72195	MRI Pelvis alternate code (listed as possible combination for enterography)

MRI Pelvis for perirectal/perianal disease (preferred)CPTCovered

72197

MRI Pelvis without and with contrast (preferred for perirectal/perianal fistula/abscess)

CT Pelvis with contrast (alternative/inferior)CPTCovered

72193

CT Pelvis with contrast (considered inferior but approvable when MRI or EUS cannot be performed)

Endoscopic ultrasound (preferred over CT for fistula evaluation)mixedCovered

No codes listed

CT Colonography (CTC)CPTCovered

74263	Screening CT colonography (only for average-risk screening as defined)
74261	Diagnostic CT colonography without contrast (approvable when colonoscopy contraindicated)
74262	Diagnostic CT colonography with contrast (approvable when IV contrast indicated for extra-colonic organs)

Ultrasound and Doppler for liver/ascites/portal hypertensionCPTCovered

76700	Abdominal ultrasound complete
76705	Abdominal ultrasound limited
93975	Duplex Doppler US of abdomen (liver/portal/hepatic veins)

Peritoneal-venous shunt studyCPTCovered

78291

Peritoneal-venous shunt patency study

Multiphase CT / MRI Liver for lesion evaluationCPTCovered

74160	CT Abdomen multiphase (without and with contrast) for liver lesion evaluation
74170	CT Abdomen with and without contrast (multiphase) - alternative code listed
74183	MRI Abdomen (listed for multiphase MRI liver in some sections)

Contrast-Enhanced Ultrasound (CEUS)CPTCovered

76978	Contrast-enhanced ultrasound, diagnostic
76979	Contrast-enhanced ultrasound, subsequent or additional

MR Elastography and MR spectroscopyCPT|Category III

76391	MR elastography
76390	MR spectroscopy
0648T	Liver Multiscan (Category III) - multiparametric MRI (example)
0649T	Liver Multiscan (Category III) - multiparametric MRI (example)

Nuclear medicine liver studies (rarely performed)CPTCovered

78201	Hepatic imaging, planar
78202	Hepatic imaging, SPECT
78215	Hepatic scintigraphy, quantification
78216	Hepatic scintigraphy, delayed imaging
78803	Hepatobiliary imaging
78830	Liver/spleen imaging

MRCP coding guidance notemixed

74183	Single MRI abdomen code (74183) covers both primary MRI abdomen and MRCP portion; reporting a second MRI code for MRCP portion is not supported
76376	3D rendering (approvable in addition to primary MRI)
76377	3D rendering (approvable in addition to primary MRI)

Ultrasound (initial liver/pancreas/RUQ)CPTCovered

76700	Ultrasound, abdominal, real time with image documentation; complete
76705	Ultrasound, abdominal, real time with image documentation; limited or single organ

Ultrasound DopplerCPTCovered

93975

Duplex scan of abdominal, retroperitoneal organs; imaging of vasculature

CT Abdomen / pancreatic protocolCPTCovered

74160	CT abdomen; with contrast, pancreatic protocol (dual phase/parenchymal and portal venous)
74170	CT abdomen and pelvis; with contrast, without and with contrast
74177	CT abdomen and pelvis with contrast

MRI abdomen / MRCPCPTCovered

74183	MRI abdomen without and with contrast
74181	MR cholangiopancreatography (MRCP)

Endoscopic ultrasound / diagnostic alternativesmixedCovered

EUS	Endoscopic ultrasound (EUS) — CPT codes vary; referenced as alternative modality
ERCP	Endoscopic retrograde cholangiopancreatography — referenced for intervention/diagnostic use

Contrast-Enhanced UltrasoundCPTCovered

76978	Contrast-enhanced ultrasound, first lesion
76979	Contrast-enhanced ultrasound, additional lesions

CT Angiography / CTACPTCovered

74174	CTA abdomen and pelvis
74175	CTA abdomen

Nuclear Medicine / PETCPTCovered

78803	Liver/spleen imaging
78215	Splenic imaging
78216	Splenic imaging alternative code
78830	Liver/spleen imaging alternative
78815	PET/CT
78700	Renal cortical imaging (DMSA)
78701	Renal imaging (alternative)
78707	Renal scan; MAG3
78708	Renal scan; other
78709	Renal scintigraphy

Renal Ultrasound with Doppler / VascularCPTCovered

76770	Retroperitoneal ultrasound, kidney(s) complete
76775	Retroperitoneal ultrasound, kidney(s) limited
93975	Transcranial Doppler (listed here as Doppler ultrasound code per document)
93976	Duplex scan of extracranial arteries (used as Doppler code reference)

Retroperitoneal / Abdominal ultrasoundCPTCovered

76770	Retroperitoneal Ultrasound
76700	Abdominal ultrasound
76705	Complete abdominal ultrasound

CT Urogram / Advanced Abdomen CTCPTCovered

74178	CT Urogram
74176	CT Abdomen and Pelvis without contrast
74177	CT Abdomen and Pelvis with contrast (and without)
74160	CT Abdomen
74170	CT Abdomen without and with contrast
74174	CTA Abdomen and Pelvis
74175	CTA Abdomen

MRI Abdomen / MR Urography / MRCPCPTCovered

74183	MRI Abdomen without and with contrast (MR Urography mentioned)
74181	MRI Abdomen without contrast
72197	MR Urography pelvic component referenced
MRCP	See MRCP guideline for appropriate CPT codes (MRCP references AB-27.1)

Ultrasound / Retroperitoneal ImagingCPTCovered

76770	Retroperitoneal Ultrasound
76700	Abdominal ultrasound
76775	Retroperitoneal ultrasound alternate code

CT Chest / Chest ImagingCPTCovered

71250	CT Chest without contrast
71260	CT Chest with contrast

3D Reconstruction / RenderingCPTCovered

76377	3-D reconstruction (CT Urogram)
76376	3-D reconstruction (alternate code)

Cardiac / Vascular / Pre-transplant StudiesCPTCovered

93306	Transthoracic echocardiography
93307	TTE alternative
93308	TTE alternative
75574	CT Coronary angiography (CCTA)
0501T	CT-FFR (CT fractional flow reserve) / related appx code
75580	CT-FFR (alternate)
93458	Left heart catheterization (examples)
93454	Left and right heart catheterization
93460	Cardiac cath code

Nuclear / Bone / PET / SPECTCPTCovered

78306	Bone scan
78803	SPECT cardiac / amyloid evaluation (example)
78830	Nuclear cardiac imaging alternative

PTLD evaluationCPTCovered

71260	CT Chest with contrast (for PTLD)
74177	CT Abdomen/Pelvis with contrast (for PTLD)

Kidney Transplant pre-transplant CTA/CTCPTCovered

74176	CT Abdomen and Pelvis without contrast
74177	CT Abdomen and Pelvis with contrast
74175	CTA Abdomen
74174	CTA Abdomen and Pelvis
72191	CTA Pelvis

Other referenced CPTsCPTCovered

72195	MRI Pelvis without/with contrast (referenced)
72197	MRI Pelvis with/without contrast (referenced earlier)
76770	Retroperitoneal ultrasound (repeat entry)

Abdominal CT/CTA/MR codes referencedCPTCovered

74160	CT Abdomen with contrast (example)
74170	CT Abdomen without and with contrast (multiphase)
74175	CTA Abdomen
74174	CTA Abdomen and Pelvis
74177	CT Abdomen and Pelvis with contrast
74183	MRI Abdomen liver protocol without and with contrast
74185	Multiphase MRA Abdomen
74181	MRCP (alternate CPT referenced with 74183)

Ultrasound and Duplex Vascular CodesCPTCovered

76700	Abdominal ultrasound; complete
76705	Abdominal ultrasound; limited
76775	Limited retroperitoneal ultrasound (use if transplanted kidney w/o Doppler)
76776	Ultrasound of transplanted kidney (commonly includes Doppler)
93975	Non-invasive vascular ultrasound for portal/TIPS (Doppler)
93976	Non-invasive vascular study (do not report with 76776)
93880	Carotid duplex unilateral/bilateral (bilateral option listed as 93882)
93882	Carotid duplex, bilateral

Cardiac and Cardiac Nuclear CodesCPTCovered

93306	Echocardiogram (TTE) pre-procedure evaluation
75557	Cardiac MRI
75561	Cardiac MRI (alternate/related code)
78803	Myocardial Tc-99m Pyrophosphate Imaging (planar/SPECT)
78830	Related nuclear cardiac imaging code
93458	Diagnostic heart catheterization
93454	Coronary angiography
93459	Diagnostic heart catheterization after CABG
93455	Coronary angiography after CABG

Elastography and MRI ElastographyCPTCovered

91200	Vibration-Controlled Transient Elastography (VCTE, e.g., Fibroscan)
76391	Magnetic Resonance Elastography (MRE) — standalone code

Other referenced imaging codesCPTCovered

70544	MRA Head (cerebral) without/with contrast code family
70545	MRA Head variations
70546	MRA Head variations

CT ChestCPTCovered

71260

CT Chest with contrast

CT Abdomen and Pelvis with contrastCPTCovered

74177

CT Abdomen and Pelvis with contrast

CT Abdomen and Pelvis without contrastCPTCovered

74176

CT Abdomen and Pelvis without contrast

CT Abdomen (single)CPTCovered

74160

CT Abdomen with contrast (example)

MRI Abdomen and Pelvis without and with contrastCPTCovered

74183	MRI Abdomen and Pelvis with and without contrast
72197	MRI Pelvis with and without contrast (paired in document)

MR EnterographyCPTCovered

74183	MR Enterography (document references same codes as MRI Abdomen/Pelvis)
74181	MR Enterography variant (document lists combinations)
72197	Pelvic MR pairing
72195	Pelvic MR without contrast pairing

PET/CTCPTCovered

78815

PET/CT whole body (document lists PET/CT for retroperitoneal fibrosis)

3D Reconstruction / RenderingCPTCovered

76377	3D rendering (CT Urogram)
76376	3D rendering (alternate code)

CT Head/Chest/Abdomen codes referencedCPTCovered

71250	CT Chest without contrast
71260	CT Chest with contrast
74177	CT Abdomen and Pelvis with contrast
74160	CT Abdomen with contrast
74150	CT Abdomen without contrast
74176	CT Abdomen and Pelvis without contrast

Provider actions — prior authorization, documentation & billing rules

Prior Authorization

Prior authorization and specialist request

Prior authorization may be required for select advanced reconstructions and specialist-requested imaging. Submit a prior authorization request when 3D rendering or advanced post-processing is planned, for pre-transplant imaging protocols, or when a PET‑MRI reporting combination is requested. Specialist requests for surgical planning (e.g., hiatal hernia, complex mass/hernia repair, transplant planning) should be documented on the PA and attached consultation notes.

Prior authorization required for 3D rendering and advanced reconstruction — include supervising physician documentation and clinical rationale.
Prior authorization advised when using PET‑MRI reporting combination; document how PET and MRI findings will be integrated and why PET‑MRI is necessary versus PET/CT or MRI alone.
Pre‑transplant imaging: follow transplant-specific protocol imaging notes and include transplant clinic request and relevant transplant evaluation findings.
For abdominal lymphadenopathy with clinical suspicion of malignancy, PET/CT prior to biopsy is recommended; document indication and how PET/CT will change management.

Background, evidence base, and definitions

These guidelines are proprietary, evidence‑based clinical guidelines developed by UnitedHealthcare to evaluate advanced imaging modalities (CT, MRI, US, PET, NM and related procedures) and guide appropriate modality selection and utilization; they are based on major society guidance and peer‑reviewed literature, are intended to support—but not replace—physician judgment, and undergo a formal annual review and update process.

Evidence	Summary
Whole-body CT in multiple myeloma	Whole-body low-dose CT supported for oncologic staging in Multiple Myeloma
Major society references	Primary references include ACR, ACG, AASLD and other society guidance cited throughout guidelines
Sensitivity: MIBG	I-123 MIBG sensitivity ~96% for non-metastatic pheochromocytoma/paraganglioma and ~79% for metastatic disease (meta-analysis)
Sensitivity: 68Ga-DOTATATE	68Ga-DOTATATE PET sensitivity ~95% for pheochromocytoma/paraganglioma in studies/meta-analysis
Elastography (VCTE vs MRE) performance	VCTE is most studied; MRE (CPT 76391) more sensitive for fibrosis >F2 and approvable when VCTE limited (BMI≥35, XL-probe failure), discordant results, LSM thresholds cited in guideline

Scope limitation: the guideline only applies to the state of Ohio and notes that requests for services described as unproven or subject to coverage/quantity limits will be evaluated using Ohio Administrative Code 5160-1-01 as part of the medical necessity review.

Term	Definition
Red flag findings	Serious signs/symptoms that require urgent advanced imaging and preclude adjudication by other criteria (examples: fever ≥101°F, history of malignancy likely to metastasize, elevated WBC >10,000, palpable concerning mass, ANC <1000, GI bleeding not obviously hemorrhoidal, moderate/severe abdominal tenderness, peritoneal signs, notation of 'surgical abdomen', suspected bariatric complication, age ≥60 with significant unintended weight loss)
Concurrent supervision	Active physician participation in and monitoring of image post-processing (design of anatomic region to be reconstructed, selection of tissues/structures, selection of images/cine loops to archive, monitoring/adjustment of 3D work product) required for CPT 76376/76377
CS-MRI	Chemical shift MRI used for adrenal characterization; definitive benign characteristic includes signal drop-out on CS-MRI (one of three modalities for benign adrenal characterization)
Li-RADS	Liver imaging reporting and data system categories guiding surveillance and follow-up (e.g., LR-1 benign -> routine US; LR-2 probably benign -> CT/MRI in 6 months; LR-3 intermediate -> CT/MRI 3–6 months; LR-4 probable HCC -> repeat/alternative imaging <3 months; LR-5 HCC confirmed -> oncology pathways)
Microscopic hematuria	Defined as ≥3 red blood cells per high-power field on microscopic urinalysis; dipstick positivity alone does NOT define microhematuria; risk-stratified management (low/intermediate/high) directs imaging (renal US ± cystoscopy for low/intermediate; CT urogram for high-risk)
VCTE	Vibration-Controlled Transient Elastography (e.g., FibroScan, CPT 91200) — widely used noninvasive liver stiffness test; typically repeated within ~3 years; LSM thresholds (guideline examples) used for fibrosis staging and to triage to MRE when limited or discordant
MRE	Magnetic Resonance Elastography (CPT 76391) — MRI-based technique to assess liver stiffness/fibrosis; standalone code; indicated when VCTE fails (XL-probe/BMI ≥35), clinical-VCTE discordance, very high VCTE LSM (e.g., 28 kPa), FIB-4 >2.67, or biopsy-proven F2–F4 fibrosis; more sensitive for fibrosis >F2
TSTC	Too Small To Characterize — lesion designation in renal imaging guidance; often no further work-up if labeled likely benign or TSTC on initial imaging
Bosniak classification	Radiologic classification of renal cysts guiding management: I and II — no further work-up; IIF — CT/MRI at 6 and 12 months then yearly for 5 years; III/IV — consider referral/biopsy/surgical management per oncology guidance

Revision history

2025-11-01effective_dateLatest

Annual evidence-based updates and interim evidence-based updates noted in policy history (02/01/2024 and 07/01/2024); current effective date Nov 1, 2025.

2024-07-01history

Interim evidence-based updates and minor editorial updates noted in policy history (07/01/2024).

2024-02-01history

General operational and condition-specific prerequisites (consolidated)

ALL of the following

General prerequisites for advanced imaging: A current clinical evaluation within 60 days or meaningful technological contact describing symptoms, relevant exam, and the focused clinical question is required for non-surveillance advanced imaging requests.

ALL of the following

Whole-body CT/MRI/PET-MRI appropriate use: Use whole-body protocols only when clinical suspicion for disseminated disease, systemic malignancy, or multifocal process exists and when results will change management. PET-MRI is appropriate when combined metabolic and high-resolution anatomic assessment will alter staging or management; document the specific reason PET-MRI is preferred over PET-CT or separate MRI.

ALL of the following

Use of guidance (77012/77021/77013/77022): Radiologic guidance codes apply per CPT definitions. Limit reporting to one guidance service per distinct target/organ per session unless multiple distinct targets are separately documented. Units billed should reflect discrete targets, not additional images or maneuvers.

ALL of the following

Unlisted procedure code use (76497/76498/78999): Unlisted codes are appropriate only when no specific CPT code exists for the service performed. Provide detailed operative and imaging documentation and imaging examples. Use specific CPT codes whenever available.

ALL of the following

Limited or follow-up CT (76380): Use when only a limited region or follow-up focused exam is needed to evaluate a previously identified finding (e.g., limited CT to re-evaluate a known drainable collection or stent position). Document why a full abdominal/pelvic study is unnecessary.

ALL of the following

Quantitative MR analysis (Category III codes): Generally considered investigational; Category III quantitative MR perfusion or other research-grade MR metrics are not routinely supported outside of validated, guideline-supported indications.

ALL of the following

Ultrasound billing rules: Images must be saved to PACS; 3D/4D rendering is not required for most diagnostic abdominal ultrasound and is not separately billable unless it meets the 3D rendering criteria. Hand-held point-of-care ultrasound without image archival in PACS is not separately billable as a diagnostic ultrasound study.

ALL of the following

Abdominal ultrasound completeness and limited study rules (76700/76705): Perform complete abdominal ultrasound when the clinical question requires evaluation of all abdominal organs; limited studies are appropriate when focused to a single organ or finding (document limited indication).

ALL of the following

Retroperitoneal ultrasound completeness and limited study rules (76770/76775): Complete retroperitoneal ultrasound includes bilateral kidneys and retroperitoneal space; limited studies may be used for focused evaluation of a single kidney or adrenal when documented.

ALL of the following

General rule: Presence of red flags (see Red Flag exclusion) precludes standard prerequisites and may warrant immediate advanced imaging adjudication.

ALL of the following

Acute/Persistent (Non-Chronic) Lower Abdominal Pain (AB-2.2): Use CT abdomen/pelvis with IV contrast for acute RLQ/RLQ pain when appendicitis is suspected in adults; ultrasound may be considered first-line in young patients or pregnant individuals. For left lower quadrant pain, consider CT with IV contrast if diverticulitis or abscess is suspected. Document localizing exam findings and labs when available.

ALL of the following

Right Upper Quadrant Pain / Suspected Gallbladder Disease (AB-2.3): Initial imaging is RUQ ultrasound. If ultrasound is inconclusive and clinical concern persists for acute cholecystitis, consider HIDA (cholescintigraphy) or CT/MRI as appropriate. HIDA may be used when sonographic findings are equivocal and clinical suspicion remains high; document prior ultrasound results.

ALL of the following

Left Upper Quadrant (LUQ) Pain (AB-2.4): Consider CT abdomen/pelvis with IV contrast for suspected splenic injury, pancreatitis, or other intra-abdominal pathology; obtain relevant labs (amylase/lipase) when evaluating pancreatic etiologies.

ALL of the following

Epigastric Pain and Dyspepsia (AB-2.5): Initial evaluation may include abdominal ultrasound or CT depending on clinical suspicion (e.g., biliary vs pancreatic). Evaluate risk factors for pancreatic cancer (weight loss, persistent pain, new-onset diabetes) and escalate to dedicated pancreatic protocol CT or MRI when indicated.

ALL of the following

Chronic Abdominal Pain (AB-2.6): Chronic or recurrent pain without red flags may require cross-sectional imaging if prior basic workup (labs, targeted ultrasound) is negative and symptoms persist or worsen; document prior evaluations and timeline.

ALL of the following

Non-operative Treatment of Acute Appendicitis (AB-2.7): When non-operative management is pursued, a single follow-up CT to evaluate response or complications may be appropriate as a one-time study; document initial imaging and clinical course.

ALL of the following

Nonspecific Abdominal Pain (AB-2.8): When pain cannot be localized, consider ultrasound for females of reproductive age and pregnancy rule-out; CT/ MRI may be used when noninvasive evaluation is nondiagnostic and clinical suspicion for serious pathology persists.

ALL of the following

Abdominal Sepsis / Suspected Abdominal Abscess (AB-3.1): CT with IV contrast is preferred for identifying intra-abdominal collections; serial ultrasound can be used for follow-up of known collections or percutaneous drain guidance when accessible.

ALL of the following

Suspected Renal/Ureteral Stone(s) (AB-4.1) and related follow-up (AB-4.2–AB-4.5): Non-contrast CT is preferred for initial detection of ureteral/renal calculi in adults. Follow-up imaging modality and timing depend on management (e.g., post-intervention residual stone assessment, stent position) and are addressed in the stone-specific criteria trees.

ALL of the following

Gastroenteritis/Enterocolitis (AB-5.1): Imaging is not routinely required for uncomplicated gastroenteritis. Consider CT abdomen/pelvis with IV contrast when high-risk features are present (severe dehydration, systemic toxicity, concern for ischemia, or failure to improve) or when alternative diagnoses (abscess, inflammatory bowel disease) are suspected.

ALL of the following

Mesenteric / Colonic Ischemia (AB-6.x): CT angiography with portal venous phase or dedicated CT angiography is indicated when mesenteric ischemia is suspected. Use contrast-enhanced imaging unless contraindicated.

ALL of the following

Post-Operative Pain Within 60 Days Following Abdominal Surgery (AB-7.1): CT with IV contrast is appropriate for suspected post-operative complications (abscess, leak, obstruction) within 60 days of abdominal surgery. Provide operative report details and recent exam findings. For superficial wound or suspected abdominal wall fluid collections, ultrasound may be useful for initial assessment and guidance for drainage.

ALL of the following

Abdominal Lymphadenopathy (AB-8.1) and Inguinal Lymphadenopathy (AB-8.2): Cross-sectional imaging (CT or MRI) is appropriate when lymphadenopathy is unexplained, progressive, associated with systemic symptoms (fever, weight loss, night sweats), or when malignancy or occult infection is suspected. Ultrasound may be first-line for accessible superficial nodes (e.g., inguinal) with ultrasound-guided biopsy as indicated.

ALL of the following

Bariatric Surgery — Preoperative assessment: Routine gallbladder ultrasound is recommended pre-bariatric surgery to identify cholelithiasis or cholecystopathy that may require concurrent management; document findings. Additional imaging (e.g., CT) only as clinically indicated.

ALL of the following

Hernias — Inguinal/femoral and groin pain: Ultrasound is first-line for evaluation of suspected inguinal or femoral hernia in physical exam–equivocal cases. CT or MRI considered when complex or occult hernia is suspected, or when evaluating for complications (incarceration, strangulation) or atypical abdominal wall pain.

ALL of the following

Spigelian/ventral/umbilical/incisional hernia: Use CT or MRI when clinical exam is inconclusive or when detailed preoperative anatomic mapping is required; ultrasound may be used for superficial or reducible hernias when exam is equivocal.

ALL of the following

Hiatal hernia imaging: Chest radiograph, barium swallow, or dedicated CT/MRI may be used per clinical indication and presence of reflux or obstructive symptoms; correlate with gastroenterology evaluation when planning intervention.

ALL of the following

Abdominal wall mass / indeterminate intra-abdominal mass: Ultrasound is often first-line for superficial abdominal wall masses; CT or MRI with contrast should be used for characterization of deep or indeterminate intra-abdominal masses and for staging when malignancy is suspected.

ALL of the following

Abnormal findings on endoscopy/colonoscopy: Cross-sectional imaging (CT enterography, MR enterography, CT abdomen/pelvis with IV contrast) may be indicated to further evaluate extraluminal extension, abscess, fistula, or masses identified on endoscopy/colonoscopy. Provide endoscopy/colonoscopy report and specific findings prompting imaging.

ALL of the following

Adrenal cortical lesions — asymptomatic: For incidental, asymptomatic adrenal lesions: use imaging characteristics (size, imaging attenuation, and washout on CT; chemical shift and signal characteristics on MRI) to classify lesions. Small (<1 cm) typical adenomas often require no further imaging; lesions >1 cm or indeterminate characteristics may require additional dedicated adrenal protocol CT or MRI per adrenal-specific criteria.

ALL of the following

Asymptomatic Adrenal Cortical Lesions - Overall Considerations: Evaluate lesion size, imaging phenotype (lipid-rich adenoma vs indeterminate), and patient risk factors. For indeterminate lesions, dedicated adrenal CT (noncontrast HU and washout protocol) or dedicated adrenal MRI is appropriate. Consider endocrine evaluation for functional status when imaging is indeterminate.

ALL of the following

Known adrenal mass with benign characteristics but new symptoms: If a previously characterized benign-appearing adrenal lesion is associated with new symptoms concerning for hormone excess or mass effect, obtain endocrine workup and consider repeat imaging with dedicated adrenal protocol to assess interval change or complication.

ALL of the following

Adrenal Hormone Excess / Symptomatic Adrenal Lesions - Overall Considerations: For suspected hormone-producing adrenal tumors or symptomatic lesions, coordinate endocrine testing prior to imaging when possible and use dedicated adrenal imaging (CT/MRI) to localize and characterize lesions; consider functional nuclear imaging (e.g., NP-59, adrenal scintigraphy, or PET) when indicated by endocrine workup and per condition-specific guidance.

ALL of the following

Small Bowel Obstruction / Suspected Small Bowel Tumor: CT abdomen/pelvis with IV contrast is preferred for suspected small-bowel obstruction to identify transition points and complications. For suspected small-bowel tumor or chronic small-bowel disease, CT enterography or MR enterography provides better mucosal and mural assessment.

ALL of the following

Gastroparesis and Dumping Syndrome: Gastric emptying scintigraphy or standardized gastric emptying studies are the appropriate diagnostic tests for suspected gastroparesis. For post-bariatric surgery patients with suspected dumping or obstruction, correlate with surgical history and use targeted imaging as indicated.

ALL of the following

Nausea and Vomiting as Primary Symptom: Imaging is indicated when alarm features are present (weight loss, persistent severe pain, GI bleeding, abnormal labs) or when symptoms are persistent and unexplained after initial evaluation. Choose modality based on likely etiology (e.g., CT for suspected obstruction, ultrasound for hepatobiliary causes, gastric emptying for suspected gastroparesis).

ALL of the following

Superior Mesenteric Artery (SMA) Syndrome: Dedicated CT or MR enterography with appropriate oral contrast protocols may demonstrate compression of the third portion of the duodenum; correlate with clinical symptoms and prior surgical history.

ALL of the following

Bloating, Gas, and Distention: Imaging is generally reserved for persistent or progressive symptoms, focal exam findings, or when obstruction, mass, or ascites is suspected. Plain radiographs and CT are useful for suspected obstruction; enteric protocols for suspected small bowel pathology.

ALL of the following

Acute and Persistent Diarrhea (Up to 30 Days): Imaging is not routinely required for uncomplicated acute diarrhea. Consider CT abdomen/pelvis with IV contrast when severe illness, systemic toxicity, concern for abscess, or failure to improve is present. For suspected inflammatory bowel disease or enteritis of unclear etiology, consider CT or MR enterography per condition specifics.

ALL of the following

Chronic Diarrhea (>30 Days): Chronic diarrhea warrants targeted evaluation; consider CT/MR enterography or colon imaging when small bowel disease or structural pathology is suspected after initial workup including stool studies and endoscopy as indicated.

ALL of the following

Irritable Bowel Syndrome (IBS): Imaging is not routinely indicated for typical IBS without alarm features. If alarm features (blood, weight loss, iron deficiency anemia, family history of colorectal cancer, new focal exam findings) are present, pursue appropriate imaging and endoscopic evaluation per other condition trees.

ALL of the following

GI Bleeding (Initial Evaluation): Hemodynamically unstable patients require urgent localization and resuscitation; CT angiography is useful for active extravasation detection and localization. For stable patients with overt GI bleeding, choose modality by suspected source (CT angiography for brisk bleeding, tagged RBC scan or endoscopy for intermittent bleeding) and coordinate with gastroenterology.

ALL of the following

GI bleeding and imaging modality preferences: Upper GI sources are primarily evaluated with endoscopy; lower GI bleeding may be evaluated with CT angiography for brisk bleeding or radionuclide bleeding scan for intermittent bleeding. For obscure bleeding, consider capsule endoscopy or enterography based on suspected lesion location.

ALL of the following

Perirectal/Perianal Disease (Crohn's disease): Pelvic MRI with dedicated perianal protocol is preferred for evaluation of fistulae, abscesses, and complex perianal disease. Endoanal ultrasound may be considered for select perianal fistula assessments when MRI is contraindicated.

ALL of the following

Celiac Disease - Indications for CT/MR Enterography: Cross-sectional enterography is indicated when complications or alternate diagnoses are suspected (e.g., strictures, malignancy, refractory symptoms) rather than for routine initial diagnosis of celiac disease.

ALL of the following

CT Colonography (CTC) - Screening and Diagnostic Use: CT colonography is acceptable for colorectal cancer screening when optical colonoscopy is incomplete or contraindicated, or when patient declines colonoscopy, following current screening intervals and bowel prep standards. For diagnostic evaluation of symptomatic patients, use modality per colon-specific criteria and coordinate with GI.

ALL of the following

Chronic Liver Disease, Cirrhosis and HCC Surveillance: Use ultrasound with or without AFP as primary surveillance for HCC in patients with cirrhosis per guideline intervals. When a focal liver lesion is identified or ultrasound is inadequate, use multiphase contrast-enhanced CT or MRI and apply LI-RADS categorization for management and follow-up guidance.

ALL of the following

Ascites initial evaluation and imaging: Ultrasound is first-line to detect and quantify ascites and to guide paracentesis. CT or MRI may be used when more comprehensive evaluation of intra-abdominal pathology is needed.

ALL of the following

Portal Hypertension imaging: Ultrasound with Doppler is first-line to evaluate portal venous flow and signs of portal hypertension. Cross-sectional imaging with CT or MRI is appropriate for evaluation of varices, portal vein thrombosis, or vascular anatomy when intervention is considered.

ALL of the following

Monitoring after Fontan Procedure: Use targeted cross-sectional imaging and echocardiography per cardiology and transplant follow-up protocols; coordinate imaging modality with the surgical/cardiology team.

ALL of the following

MRCP indications and coding guidance: MRCP is indicated for ductal evaluation when ERCP is not immediately required or as a noninvasive alternative. Use dedicated MRCP sequences; document the clinical question and prior ultrasound or CT findings prompting MRCP.

ALL of the following

Gallbladder imaging and polyp surveillance: Cholelithiasis and symptomatic gallbladder disease—initial RUQ ultrasound. For gallbladder polyps, follow size- and risk-based surveillance intervals per condition-specific guidance; consider cholecystectomy referral for symptomatic stones or polyps meeting size/risk thresholds.

ALL of the following

Liver lesion characterization: Use multiphase contrast-enhanced CT or MRI with liver-specific protocols to characterize indeterminate focal liver lesions detected on ultrasound. Apply LI-RADS for patients at risk of HCC; document prior imaging and liver disease status.

ALL of the following

Fatty liver (MASLD) imaging: Ultrasound is the common initial imaging for suspected fatty liver; consider controlled attenuation parameter (VCTE) or MRI-PDFF for quantitative assessment or when fibrosis needs noninvasive staging adjuncts.

ALL of the following

Polycystic liver disease (PLD): Use ultrasound for initial evaluation; CT or MRI for detailed anatomic mapping when surgical planning or complication assessment is required.

ALL of the following

Isolated/incidental hepatomegaly: Correlate with labs and history; choose ultrasound for initial assessment and CT/MRI for further characterization when focal lesions or structural disease suspected.

ALL of the following

Liver lesion initial evaluation / abnormal liver chemistries: Tailor imaging (US, CT, MRI) to the clinical question and labs; document which tests have been performed and results prior to advanced imaging request.

ALL of the following

Pancreatic cystic lesions — initial evaluation and surveillance: Use MRI with MRCP or pancreatic protocol CT for initial characterization of pancreatic cysts. Surveillance intervals depend on cyst features and guidelines; maintain documentation of cyst morphology and size changes.

ALL of the following

Incidental pancreatic mass or suspected metastatic disease to pancreas: Use pancreatic protocol CT or MRI with contrast for characterization and staging; coordinate with oncology for further management.

ALL of the following

Acute pancreatitis — initial and follow-up imaging: Imaging is not required to diagnose mild acute pancreatitis with classic presentation; use contrast-enhanced CT when diagnosis is uncertain, severe course, or to evaluate complications (necrosis, abscess).

ALL of the following

Chronic pancreatitis imaging: Use CT or MRCP/MR pancreas protocols for evaluation of complications, ductal changes, or malignancy risk in chronic pancreatitis.

ALL of the following

Exocrine pancreatic insufficiency (EPI): Imaging is not diagnostic for EPI; consider imaging when structural pancreatic disease is suspected as the cause of EPI.

ALL of the following

Incidental Splenic Findings (AB-34.1) and Splenic Trauma (AB-34.2): Use CT with IV contrast for initial evaluation of suspected splenic injury or significant incidental solid splenic lesions. Ultrasound may be used for superficial cystic lesions and follow-up in select stable cases.

ALL of the following

Pre-operative Assessment for Robotic Kidney Surgery (AB-35.2): Dedicated contrast-enhanced CT or MRI with vascular phase imaging is appropriate for preoperative anatomic mapping for robotic partial or radical nephrectomy; include arterial and venous phase when planning complex vascular management.

ALL of the following

Renal Failure Imaging (AB-36.1): Tailor imaging to the clinical question; use ultrasound for initial assessment of obstruction or transplant evaluation. Use contrast-enhanced CT or MRI judiciously in renal impairment and document risk/benefit when contrast is necessary.

ALL of the following

Hematuria Evaluation (AB-39.x): Risk-stratify hematuria (asymptomatic microscopic vs gross hematuria, presence of risk factors). CT urography is preferred for evaluation of higher-risk hematuria and for flank pain suspicious for stone; ultrasound may be appropriate for low-risk microscopic hematuria initial evaluation or when CT contrast is contraindicated. Document risk factors and prior studies.

ALL of the following

Hydronephrosis of Unexplained or Indeterminate Cause (AB-39.4): Ultrasound often first-line; CT urography indicated when cause is unclear, obstruction level needs surgical planning, or malignancy is suspected.

ALL of the following

Urinary Tract Infection — Upper (Pyelonephritis) (AB-40.1) and Lower (AB-40.2): Imaging not routinely required for uncomplicated UTI. Consider CT or ultrasound when complicated infection, suspected abscess, obstruction, or atypical course is present; provide clinical context and labs.

ALL of the following

Transplant imaging: Liver and Kidney transplant pre- and post-imaging (AB-42): Pre-transplant imaging for recipient and donor should include cross-sectional mapping appropriate to organ and surgical plan. Post-transplant imaging for suspected complication (vascular thrombosis, biliary leak, collection) should be tailored to the clinical question; nuclear studies may be used per transplant protocols.

ALL of the following

Post-Transplant Lymphoproliferative Disorder (PTLD) (AB-42.4): Use cross-sectional imaging and PET-CT per oncology/infectious disease guidance when PTLD suspected; provide clinical context and prior immunosuppression history.

ALL of the following

Kidney Transplant Pre-Transplant Imaging (AB-42.5) and donor imaging: Use Doppler ultrasound for initial vascular assessment; CT or MR angiography may be required for vascular mapping of donors and recipients. Document surgical planning needs.

ALL of the following

Pre-Transplant / Donor Imaging — General: Imaging should address anatomic suitability and donor safety; use modality that provides required vascular and parenchymal detail for operative planning.

ALL of the following

Kidney Transplant — Post-Transplant Imaging: Use ultrasound as initial modality for graft perfusion and hydronephrosis; use CT or MR when vascular or complex parenchymal complications are suspected.

ALL of the following

Liver Elastography (AB-45): Use VCTE (FibroScan) or MRE per indication and availability. Use MRE when higher accuracy for fibrosis staging is required or when concurrent MRI is being performed; coordinate modality choice with hepatology.

ALL of the following

Suspected Neuroendocrine Tumors of the Abdomen (AB-44): Use appropriate anatomic imaging (CT/MRI) and consider functional imaging (somatostatin receptor PET) per tumor type and staging needs; coordinate with oncology and nuclear medicine.

ALL of the following

Magnetic Resonance Elastography (MRE) vs VCTE guidance: Use MRE when MRI is already indicated or when more precise fibrosis mapping is required; VCTE may be used for point-of-care noninvasive assessment of fibrosis when MRE unavailable.

ALL of the following

Hiccups imaging indications: Imaging is rarely indicated for hiccups alone; consider imaging when persistent hiccups are associated with neurologic signs, chest/abdominal pain, or other concerning features.

ALL of the following

Retroperitoneal Fibrosis imaging frequency and modality selection: Use CT or MRI to evaluate suspected or known retroperitoneal fibrosis; select modality for serial follow-up based on need to avoid radiation and local expertise; interval imaging frequency based on disease activity and treatment response.

ALL of the following

Fistulae imaging indications: Use MRI (enterography or pelvic MRI) to evaluate suspected enteric or perianal fistulae; CT enterography or contrast-enhanced CT may be used when MRI contraindicated or not available. Provide prior endoscopic and surgical history.

ALL of the following

Preserve all condition-specific documentation and ensure criteria-specific thresholds, imaging phase, and protocols are requested when applicable (e.g., multiphase liver CT, pancreatic protocol, CT urography, MR enterography).

OpenPayer

Adult Abdomen Imaging Guidelines (For Ohio Only)

Coverage summary and scope

Medical-necessity criteria (condition-based trees)

Coding tables and status groups

Provider actions — prior authorization, documentation & billing rules

Background, evidence base, and definitions

Revision history