CurrentUnitedHealthcarePolicy CSRAD015OH.E

Pediatric Abdomen Imaging Guidelines (Ohio)

Clinical guideline governing advanced imaging and procedures for pediatric abdominal conditions for UnitedHealthcare members in Ohio; applies to providers requesting imaging and to utilization review for medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

PolicyPediatric Abdomen Imaging Guidelines (Ohio)

Policy CodePolicy CSRAD015OH.E

Change TypeNo material changes

Effective DateFebruary 3, 2026

Next Review DateN/A

Key ActionSubmit pertinent clinical records and documentation to establish medical necessity when requesting advanced imaging or other designated procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

168total pages

V1.0.2026guideline version

≤18applies to age

Ohioapplicable state

2026-02-03effective

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Coverage Criteria and Condition-Specific Indications

Right Lower Quadrant Pain (Appendicitis) (PEDAB-3)

Covered when ALL of the following are met:

ALL of the following

Right Lower Quadrant (RLQ) Pain — Ultrasound (CPT 76700 or 76705) is the medically necessary initial examination for suspected appendicitis.
If ultrasound is positive or diagnostic for uncomplicated appendicitis, no further imaging is necessary.
If the appendix is not visualized on ultrasound and the white blood cell count is not elevated, no further imaging is necessary in nearly all cases unless the treating physician directs otherwise.
CT Abdomen and Pelvis with contrast (CPT 74177) or MRI Abdomen and Pelvis without contrast (CPT 74181 and CPT 72195) or MRI Abdomen and Pelvis without and with contrast (CPT 74183 and CPT 72197) is medically necessary for ANY of the following: individuals who are overweight (BMI ≥85th percentile for age); insufficient local ultrasound expertise; ultrasound findings are inconclusive; clinical suspicion of or initial imaging suggestive of complication (e.g., abscess, bowel obstruction).
If the appendix is absent on imaging, follow the Generalized Abdominal Pain (PEDAB-2) guideline for further evaluation.

Flank Pain / Renal Stone (PEDAB-4)

Covered when ALL of the following are met:

ALL of the following

Presence of any red flag findings per General Guidelines (PEDAB-1.0) precludes adjudication based on other criteria and may necessitate immediate advanced imaging.
Ultrasound (CPT 76770 or CPT 76775) is the medically necessary initial study for pediatric individuals with flank pain or suspected renal/ureteral stone.
CT Abdomen and Pelvis without contrast (CPT 74176) is medically necessary if ultrasound is inconclusive for suspected renal/ureteral stone.
MRI Abdomen (CPT 74183) and Pelvis (CPT 72197) without and with contrast is medically necessary if CT is inconclusive or when there is significant concern for cumulative radiation exposure from frequent CT use for that individual.

Acute Gastroenteritis (PEDAB-6) — Advanced Imaging

Covered when ALL of the following are met:

ALL of the following

Advanced imaging is not medically necessary in pediatric acute gastroenteritis unless there is concern for an alternative diagnosis or red flag features as listed in General Guidelines (PEDAB-1.0).
CT Abdomen and Pelvis with contrast (CPT 74177) is medically necessary if abdominal red flag symptoms are present.
Additional imaging should be tailored to specific symptoms and follow the relevant guideline sections (e.g., Generalized Abdominal Pain, RLQ pain, RUQ pain, IBD, Constipation/Diarrhea, Abdominal Mass, Intussusception, Bowel Obstruction, LLQ pain).

Spleen (PEDAB-26)

Covered when ALL of the following are met:

ALL of the following

Spleen imaging indications in pediatric individuals align with adult guidelines but include pediatric-specific considerations to minimize radiation exposure.
MRI is preferred over CT when possible to reduce radiation exposure in children.
Nuclear medicine spleen imaging (CPT 78185) is medically necessary when CT is unavailable for: splenic trauma; evaluation of splenic function; suspected splenic mass, cyst, abscess, infarct, or metastasis; radiation treatment planning; asplenia.
For suspected functional accessory spleen, CPT 78215 or CPT 78216 may be used instead of CPT 78185 if requested.

Modality- and Condition-Specific Covered Indications

CPT/HCPCS Codes and Code Groups

Experimental/Investigational CPTCPTExperimental

C9791

MRI utilizing Xenon Xe 129 for contrast (considered investigational/experimental)

3D Rendering CodesCPT

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 and Related CodesCPT

19085	Biopsy, breast, with placement of breast localization device(s)... first lesion, including MR guidance
19086	Biopsy, breast... 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 for, and monitoring of parenchymal tissue ablation
77021	MR guidance for needle placement
77022	MR guidance for, and monitoring of parenchymal tissue ablation

Unlisted Procedure CodesCPT

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional)
78999	Unlisted procedure, diagnostic nuclear medicine

Limited CTCPT

76380

Limited or follow-up CT

SPECT/CT and related nuclear medicineCPT

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)

Abdomen and PET procedure codesCPTCovered

74181	MRI Abdomen without contrast
74182	MRI Abdomen with contrast
74183	MRI Abdomen without and with contrast
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
74178	CT Abdomen and Pelvis without and with contrast

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Nuclear medicine abdomen codesCPTCovered

78075	Adrenal Nuclear Imaging Cortex and/or Medulla
78185	Spleen Imaging Only with or without Vascular Flow
78201	Liver Imaging Static
78202	Liver Imaging with Vascular Flow
78215	Liver and Spleen Imaging Static
78216	Liver and Spleen Imaging with Vascular Flow
78226	Hepatobiliary System Imaging, Including Gallbladder When Present
78227	Hepatobiliary System Imaging with Pharmacologic Intervention, Including Quantitative Measurement(s)

CT/MRI procedure 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/Nuclear procedure codesCPT

76497	Unlisted CT procedure (for radiation planning or surgical software)
74175	CTA Abdomen
74174	CTA Abdomen and Pelvis
78811	PET limited area (not used in pediatrics)
78812	PET skull base to mid-thigh (not used in pediatrics)
78813	PET whole body (not used in pediatrics)
78814	PET with CT limited area (rarely used in pediatrics)
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 procedure codesCPT

78261	Gastric mucosa imaging / Gastroesophageal reflux study
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 (Nuclear) with Vascular Flow
78707	Kidney Flow and Function, Single Study without Pharmacologic Intervention
78708	Kidney Imaging with Vascular Flow and Function with Pharmacological Intervention, Single

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Ultrasound and duplex codesCPTCovered

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

Appendicitis-related imaging codesCPT

76700	Ultrasound, abdominal, real time with image documentation; limited or follow-up (used here for initial ultrasound)
76705	Ultrasound, abdominal, real time with image documentation; complete
74177	CT abdomen and pelvis with contrast
74181	MRI abdomen and pelvis without contrast
74183	MRI abdomen and pelvis without and with contrast
72195	MRI pelvis without contrast
72197	MRI pelvis without and with contrast

Flank pain / renal stone imaging codesCPT

76770	Ultrasound, limited or complete, retroperitoneal (kidneys/adrenal)
76775	Ultrasound, bilateral, renal
74176	CT abdomen and pelvis without contrast
74183	MRI abdomen without and with contrast
72197	MRI pelvis without and with contrast

Upper and lower urinary tract imaging and nuclear medicine codesCPT

76770	Ultrasound, retroperitoneal (kidneys/adrenal)
76775	Ultrasound, renal, bilateral
78707	Radioisotope renogram; single study, quantitative (MAG3 diuretic renography)
78708	Radioisotope renogram; with flow studies
78709	Radioisotope renogram; with cortical imaging
78803	DMSA renal cortical imaging
74177	CT abdomen and pelvis with contrast
78740	Radiopharmaceutical voiding cystogram (ureteral reflux study)
78700	Renal cortical imaging, planar, static
78701	Renal cortical imaging, SPECT

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Advanced imaging for acute gastroenteritisCPTCovered

74177

CT Abdomen and Pelvis with contrast

Ultrasound for hematuriaCPTCovered

76770	Ultrasound, adult/pediatric, complete or specified; kidney(s)
76775	Ultrasound, kidney, real time with image documentation; limited
76856	Ultrasound, bladder, adults and children; complete
76857	Ultrasound, bladder, limited

CT without contrast — painful hematuriaCPTCovered

74176

CT Abdomen and Pelvis without contrast

CT with contrast — traumatic hematuria / suspected bladder injuryCPTCovered

74177	CT Abdomen and Pelvis with contrast
72193	CT Pelvis with bladder contrast (CT Cystography)

RUQ pain imaging modalitiesCPTCovered

76700	Ultrasound, abdominal, real time with image documentation; limited
78226	Hepatobiliary imaging; static or blood flow, with tracer, including radiopharmaceutical
78227	Hepatobiliary imaging; including pharmacologic intervention (e.g., sincalide)
74183	MRI Abdomen with and without contrast
74160	CT Abdomen with contrast
74181	MRI Abdomen without contrast

Enterography and pelvis MRI codes for IBD/Crohn diseaseCPTCovered

74183	MR Enterography / MRI Abdomen with and without contrast
74181	MRI Abdomen without contrast
72197	MRI Pelvis without and with contrast
72195	MRI Pelvis without contrast
74177	CT Enterography / CT Abdomen and Pelvis with contrast
72196	MRI Pelvis with contrast

3-D reconstruction for surgical planningCPTCovered

76377	3D rendering with interpretation and reporting
76376	3D rendering with interpretation and reporting; more complex

Imaging CPT Codes (postoperative / abscess / nuclear medicine)CPTCovered

74177	CT Abdomen and Pelvis with contrast
76700	Ultrasound Abdomen
76705	Ultrasound Abdomen complete
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 imaging (unspecified)
78801	Radiopharmaceutical imaging (variant)
78802	Radiopharmaceutical imaging (variant)

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CT and Ultrasound Codes (constipation/diarrhea, masses, vascular)CPTCovered

74160	CT Abdomen with contrast
74150	CT Abdomen without contrast
74176	CT Abdomen and Pelvis without contrast
76770	Complete retroperitoneal Ultrasound
93975	US with Doppler (general vascular)
93976	Duplex ultrasound, peripheral

Vascular and renal imaging codesCPTCovered

93306	Echocardiography, complete
74175	CTA Abdomen
74185	MRA Abdomen
78707	Renal nuclear imaging (blood flow/functional)
78708	Renal nuclear imaging (DRF/differential)
78709	Captopril renography

Doppler ultrasound for mass vascularityCPTCovered

93975

US with Doppler to evaluate vascular supply (listed for intra-abdominal mass)

Renovascular and cardiac evaluation codesCPTCovered

74175	CTA Abdomen
74185	MRA Abdomen
93306	Echocardiography
78707	Nuclear renal imaging
78708	Nuclear renal imaging
78709	Nuclear renal imaging

Liver lesion, biliary, elastography, and ultrasound codesCPTCovered

76700	US Abdomen (initial)
76705	Repeat US Abdomen
74183	MRI Abdomen without and with contrast (includes MRCP variants)
74160	CT Abdomen with contrast
76978	Contrast-Enhanced US (CEUS) per study
76979	Contrast-Enhanced US (CEUS) additional codes
74181	MRI Abdomen with MRCP (cholangiography)
74170	CT Abdomen with multiphase liver protocol
78201	Nuclear medicine liver imaging
78202	Nuclear medicine liver imaging

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Nuclear medicine liver imaging (when US/CT/MRI unavailable)CPTCovered

78201	Nuclear medicine liver imaging (listed among options)
78202	Nuclear medicine liver imaging
78803	Nuclear medicine liver imaging
78215	Nuclear medicine for suspected accessory spleen
78216	Nuclear medicine for suspected accessory spleen

Liver ElastographyCPTCovered

91200	Transient elastography or VCTE
76391	Magnetic resonance elastography

Adrenal Lesions and Nuclear ImagingCPTCovered

76770	Retroperitoneal ultrasound (adrenal follow-up)
74183	MRI abdomen without and with contrast
74170	CT abdomen without and with contrast
78800	MIBG planar imaging (possible)
78801	MIBG planar imaging (alternative)
78802	MIBG planar imaging (alternative)
78803	MIBG planar imaging (alternative)
78804	MIBG planar imaging (alternative)
78830	MIBG SPECT/CT (hybrid)
78831	MIBG SPECT/CT (hybrid)

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Transfusion-associated Hemochromatosis ImagingCPTCovered

74181	MRI abdomen without contrast (liver iron evaluation)
75557	MRI cardiac without contrast (cardiac iron evaluation)
71550	MRI chest without contrast (evaluates heart and liver iron when requested)

Indeterminate Renal Lesion and RenographyCPTCovered

74183	MRI abdomen without and with contrast (complex renal cyst)
74160	CT abdomen with contrast (simple cyst symptomatic when surgical planning)
74170	CT abdomen without and with contrast (complex renal cyst)
78708	Diuretic renography one kidney
78709	Diuretic renography both kidneys

Hydronephrosis Imaging and Follow-upCPTCovered

76771	Retroperitoneal ultrasound for antenatal hydronephrosis
76770	Retroperitoneal ultrasound (obstructive uropathy)
78707	Diuretic renography
72197	MRU — Magnetic resonance urography (procedure code referenced in text)

Referenced CPT CodesCPT

76771	Retroperitoneal ultrasound (evaluation of antenatal hydronephrosis)
76770	Retroperitoneal ultrasound (general abdominal retroperitoneal)
76700	Abdominal ultrasound (noted in adjacent sections for polycystic kidney disease)
78707	Diuretic renography, renal imaging (as referenced for obstructive uropathy)
78708	Diuretic renography, multiple or with quantification (as referenced)
78709	Diuretic renography additional code referenced
74183	Magnetic resonance urography (MRU)
72197	MRI pelvis/urography component referenced with MRU
74160	CT abdomen with contrast
78185	Nuclear medicine spleen imaging

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CT sequences/slices — no defined minimum/maximum for CT CPT codes

CT sequences/slicesNo minimum or maximum number of sequences or slices is defined for any CT CPT code (AMA/CPT does not assign sequence/slice counts).

Guidance on extra slicesA few additional slices or sequences are not uncommon and CT protocols are influenced by clinical situation; limited CT (CPT 76380) should not be used to cover 'extra slices' with diagnostic CT codes.

Limited CT definitionCPT 76380 describes limited or follow-up CT when the work of a full diagnostic code is not performed.

Low absolute neutrophil count threshold

Low absolute neutrophil count thresholdAbsolute neutrophil count (ANC) < 1000 is listed among red-flag findings requiring additional investigation.

Context for ANCLow WBC including ANC <1000 is one of multiple red flags that preclude initial ultrasound-first approach and prompt advanced evaluation.

ImplicationPresence of ANC <1000 should prompt consideration of expedited imaging and documentation of clinical concern.

BMI threshold for advanced imaging (≥85th percentile for age)

BMI thresholdBMI ≥85th percentile for age is specified as a criterion to proceed from ultrasound to CT or MRI for appendicitis evaluation (overweight individuals).

ApplicationUsed to justify cross-sectional imaging when ultrasound is inadequate or patient habitus limits ultrasound accuracy.

Modality considerationMRI or CT (per guideline) may be used in overweight individuals to evaluate appendicitis or complications.

Blood pressure diagnostic threshold (≥95th percentile x ≥3 visits) for pediatric hypertension

Pediatric hypertension diagnostic ruleDiagnosis generally requires ≥3 auscultatory‑confirmed blood pressure readings ≥95th percentile on different visits before imaging for secondary causes.

ABPM optionAmbulatory blood pressure measurement (ABPM) recordings may be used and downloaded for analysis to support diagnosis.

Initial imaging triggersOnly after confirmed hypertension (per above) should Doppler/duplex US, CTA/MRA, or nuclear renal imaging be considered per severity and suspicion.

Lesion size threshold (<3cm vs >3cm) guides imaging pathway and surveillance

Lesion size thresholdsLesions <3 cm versus >3 cm guide imaging pathway: indeterminate lesions <3 cm may be evaluated with CEUS or MRI/CT if CEUS unavailable; lesions >3 cm generally require MRI (74183) or CT (74160).

Additional small‑lesion ruleIndeterminate lesion <1 cm in high‑risk individuals may require short‑interval MRI follow-up at 3–6 months if biopsy not possible.

Surveillance implicationLesion size influences need for further characterization and surveillance frequency per lesion type (see liver lesion surveillance rules).

Surveillance intervals for resected choledochal cysts

Choledochal cyst post-resection schedule (Years 1–20)Immediately after resection: ultrasound AND MRI Abdomen with cholangiography; Years 1–20: ultrasound biannually and MRI with cholangiography every 3 years (MRI may be used in lieu of US when indicated).

Choledochal cyst schedule (Years 21–40)Years 21–40 after resection: ultrasound every 3 years and MRI every 4 years (MRI may be used in lieu of ultrasound when indicated).

Residual cystic tissueIf residual cystic tissue is present after resection, ultrasound annually is recommended.

Transfusion exposure threshold for transfusion-associated hemochromatosis (>20 transfusions)

Transfusion exposure risk threshold>20 transfusion episodes is identified as the exposure commonly associated with transfusion‑associated hemochromatosis and warrants screening imaging consideration.

Screening intervalScreening MRI (T2* techniques) is medically necessary every 12 months for chronically transfused individuals at risk.

Monitoring during treatmentImaging every 3 months is medically necessary for treatment response monitoring in individuals receiving active chelation or phlebotomy.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior authorization and medical necessity — decisions based on evidence-based guidelines; submit clinical info

Prior authorization and medical necessity decisions are based on evidence‑based guidelines. Submit pertinent clinical information including a detailed history, physical exam, relevant laboratory data, and prior imaging/study reports that demonstrate how the requested advanced imaging will affect patient management. Requests lacking a pertinent clinical evaluation, duplicate imaging history, or sufficient supporting documentation may be denied for failure to establish medical necessity.

Include prior imaging studies and reports when available.
Document conservative care and response when escalation to advanced imaging is requested.
Red flag findings per General Guidelines (PEDAB-1.0) preclude adjudication on other criteria.

Documentation Required

Prior authorization requires submission of medical records and prior imaging history

Prior authorization requires submission of prior imaging history and medical records. Reviewers will consider overutilization risk (duplicate studies, unnecessary double‑contrast CT, or adult CT protocols used for children) and may deny requests without documentation showing how the new study will change management.

Provide dates and findings of recent imaging and clinical notes since onset or change in symptoms.
Explain why previous studies are insufficient and how the requested study will alter treatment.

Prior Authorization

Prior authorization for 3D rendering — supervision and authorization may be required

3D rendering codes (CPT 76376, 76377) require documentation of concurrent physician supervision/participation during post‑processing. These 3D codes may require prior authorization even if the parent study (e.g., ultrasound or echocardiography) does not require authorization.

Document active physician participation: region selected, tissue types to display, images/cine loops archived, and adjustments made during reconstruction.
CPT 76376 = no independent workstation; CPT 76377 = independent workstation required.
Prior authorization may be required for CPT 76376/76377 even when the base study is pre-authorized or does not require authorization.

Billing Rule

Reporting for PET/MRI and Whole-Body MRI — use PET whole-body CPT 78813 + MRI unlisted CPT 76498 when criteria met

PET/MRI and Whole‑Body MRI have specific reporting and coding rules. PET/MRI may be medically necessary only when PET/CT criteria are met and PET/CT is unavailable; report PET/MRI using PET whole‑body (CPT 78813) plus MRI unlisted (CPT 76498). Whole‑body MRI should be reported using CPT 76498.

Do not report PET/MRI using other code combinations; use 78813 + 76498 when criteria are met.
WBMRI has no dedicated CPT codes — CPT 76498 is the appropriate code for whole‑body MRI.
Diagnostic MRI codes may be medically necessary concurrently when clinically appropriate.

Documentation Required

Advanced imaging requires documented indication — CT/MRI/Nuclear/VCUG only when section-specific criteria met

Advanced imaging requests must include a clear, documented clinical indication tied to the specific guideline criteria. Ultrasound should generally be performed first (ultrasound‑first requirement) unless red flags apply or the condition‑specific guideline states otherwise.

Provide indication, exam timing, prior ultrasound results when applicable, and relevant labs (e.g., WBC, inflammatory markers).
If ultrasound is non‑diagnostic or inconclusive, document this and why CT/MRI or nuclear imaging is needed.
Red flag findings (PEDAB-1.0) remove the requirement for initial ultrasound and must be documented.

Prior Authorization

Enterography modalities for IBD — MRE and CTE specified as medically necessary when indicated

Enterography modalities for IBD (MR Enterography or CT Enterography) are medically necessary when used to assess disease severity, complications, or when endoscopy/inflammatory markers are suggestive or inconclusive. MR Enterography is preferred to reduce radiation exposure in children.

Acceptable codes: MR Enterography (CPT 74183 or combination 74181 + 72197/72195), CT Enterography (CPT 74177).
Provide supporting documentation: endoscopy findings, fecal calprotectin, CRP, or fecal lactoferrin values as applicable.
Enterography may be requested prior to endoscopy if coordinated with the endoscopist.

Prior Authorization

Prior authorization may be required for specified abdominal imaging studies

Prior authorization may be required for specified abdominal imaging and advanced imaging codes. Verify payer prior authorization requirements before scheduling.

Common abdominal codes referenced include CPT 74160, 74176, 74177, 74181, 74183, 72195, 72197, 76498, 76391, 76380, and nuclear codes (e.g., 78707-78709, 78800-78803).
Some 3D rendering and unlisted procedural codes may require separate authorization even when base imaging is pre-authorized.

Prior Authorization

Prior authorization may be required for advanced imaging and elastography codes (e.g., MRE, transient elastography)

Prior authorization may be required for advanced imaging and elastography codes. MRE (CPT 76391) and transient elastography (CPT 91200) have defined sequencing requirements; verify criteria before requesting authorization.

Transient elastography (CPT 91200) is the initial staging modality for liver fibrosis; MRE (CPT 76391) is indicated when transient elastography fails, BMI ≥30, or clinical conflict exists.
Provide documentation of prior transient elastography and reason for escalation to MRE when applicable.

Billing Rule

Affected codes — verify against guideline criteria when requesting authorization

Affected CPT codes must be verified against guideline criteria at the time of request. Single‑study approval rules, timing windows, and mutually exclusive code reporting requirements apply and may affect authorization.

CPT 71550 (MRI chest) used to evaluate both heart and liver iron should be approved as a single study and not with other codes for the same indication.
CPT 76380 (limited CT) is not medically necessary for treatment planning and should not be used to report extra slices.
Do not report CPT 76376/76377 with CPT 77011 or with modalities listed in the policy exclusions (e.g., PET, CTA, cardiac CT).

Note

Prior authorization note — check federal/state/contractual requirements before use

Prior authorization note: check federal, state (OAC), and contractual benefit rules before use. In case of a conflict, federal/state/contractual requirements govern.

This policy interprets standard benefit plans; other plan terms may differ and take precedence.
UnitedHealthcare reserves the right to modify policies and guidelines as necessary.

Denial Risk

Requests for services stated as unproven — may be denied

Requests for services stated as unproven, experimental, or lacking evidence may be denied. Whole‑body CT screening and unsupported whole‑body MRI applications (outside specified syndromes) are examples of non‑covered or not generally supported services.

WBMRI is generally not supported except for select cancer predisposition syndromes and certain oncologic indications; report with CPT 76498 when appropriate.
Whole‑body CT screening for asymptomatic individuals is not a covered benefit and will be denied.

Billing Rule

Inappropriate duplicate code reporting — do not report conflicting localization and diagnostic CT codes for same session

Do not report inappropriate duplicate or conflicting CPT codes for the same imaging session. Certain localization, diagnostic, and 3D post‑processing codes are mutually exclusive and should not be billed together.

Do not report both CPT 70486 and CPT 77011 for the same CT stereotactic localization session.
Do not report CPT 76380 with other full diagnostic CT codes to cover 'extra slices'.
3D rendering codes (76376/76377) should not be billed with CAD, MRA, CTA, PET, PET/CT, stereotactic localization (77011/70486), mammography, or CT colonography.

Documentation Required

Clinical evaluation prerequisite — advanced imaging should be preceded by pertinent clinical evaluation and basic imaging

A clinical evaluation (history, exam, labs, and basic imaging such as ultrasound or plain radiographs) should precede most advanced imaging requests unless guideline‑supported scheduled surveillance or red flags apply.

Meaningful technological contact (telehealth, phone, or messaging) may satisfy the clinical evaluation requirement in some circumstances.
Condition‑specific guideline sections may require face‑to‑face evaluations.

Documentation Required

Use of MRI in immediate postoperative abscess evaluation — must be feasible in similar timeframe as CT

MRI may replace CT for immediate postoperative abscess evaluation only if MRI can be completed in a timeframe similar to CT. If MRI delays care, CT remains the appropriate choice.

When requesting MRI instead of CT for postoperative complications, document feasibility and expected timeliness compared with CT.
If MRI is impractical for timely evaluation, CT Abdomen and Pelvis with contrast (CPT 74177) is medically necessary.

Denial Risk

Denial triggers for unmet indications — requests not meeting listed medically necessary indications may be denied

Requests that do not meet the listed medically necessary indications may be denied. Ensure the request clearly maps to one or more condition‑specific criteria in the guideline and includes supporting documentation.

Provide specific clinical indications, prior test results, and rationale tying the requested study to guideline criteria.
Lack of documentation of indication, timing, or clinical impact are common denial triggers.

Billing Rule

Single-study approval rule for CPT 71550 — should not be approved with other codes when used to evaluate both heart and liver iron

Single‑study approval rule: certain codes (e.g., CPT 71550 for combined heart and liver iron) are intended to be approved as single studies and should not be authorized in combination with other codes for the same indication.

CPT 71550 can be approved alone to evaluate both heart and liver iron and should not be approved with other codes for that same purpose.
If separate organ studies are requested instead of CPT 71550, provide clinical rationale.

Denial Risk

Timing-based coverage risk — performing postnatal ultrasound or surveillance outside specified windows may not meet coverage criteria

Timing-based coverage risk: perform postnatal and surveillance studies within the guideline‑specified windows. Outside these windows, coverage may not be met.

Postnatal ultrasound timing for antenatal hydronephrosis is specified (within 24 hours for certain infants, after seven days for mild AHN, and a second study at 4–6 weeks); document timing of exams.
Surveillance intervals for liver lesions and other follow-up imaging are specified in condition sections — adhere to those schedules.

Prior Authorization

Using CT Abdomen and Pelvis with contrast — reserve for guideline-specified acute settings and document red flags or justification

CT Abdomen and Pelvis with contrast (CPT 74177) is medically necessary in specified acute settings (e.g., gastroenteritis with red flags, traumatic hematuria, complicated pyelonephritis, postoperative complications) but should be reserved when indicated per the guideline. Ultrasound or MRI may be preferred when appropriate to reduce radiation exposure.

Document red flag signs/symptoms when requesting CPT 74177 for acute gastroenteritis or abdominal pain.
Use ultrasound-first for appendicitis, renal stone evaluation, and first-time pediatric UTI unless red flags or inconclusive ultrasound.
When MRI is readily available and timely for suspected bowel obstruction, MRI is preferred over CT.

Documentation Required

Required clinical documentation — include history, exam, labs, prior imaging, and condition‑specific data

Required clinical documentation for prior authorization and medical necessity requests includes: history of present illness, physical exam findings, relevant lab results, prior imaging reports and dates, prior conservative treatment and response, and condition‑specific items (e.g., inflammatory markers for IBD, WBC for appendicitis, repeat BP measures for hypertension).

For IBD: include endoscopy/colonoscopy findings and inflammatory markers (fecal calprotectin, CRP, fecal lactoferrin) when requesting enterography.
For appendicitis: include ultrasound result and WBC to support decision-making when no further imaging is requested.
For suspected hypertension: provide repeated BP measurements (generally ≥3) or ABPM data when used.

Billing Rule

77011 vs diagnostic CT documentation — stereotactic localization vs diagnostic interpretation

Distinguish stereotactic localization (CPT 77011) from diagnostic CT codes. Use CPT 77011 for technical-only, non‑interpreted localization scans; if a diagnostic CT is performed and interpreted, use the appropriate diagnostic CT code, but do not report both for the same session.

Do not report CPT 70486 and CPT 77011 for the same CT localization session.
3D rendering should not be reported with CPT 77011 (the procedure inherently generates a 3D dataset).

Documentation Required

Ultrasound result and WBC documentation — support decision-making for no further imaging

Ultrasound findings and WBC documentation are key for appendicitis and other abdominal decisions. If the appendix is not visualized and WBC is not elevated, further imaging is usually unnecessary; document the referring physician's evaluation and plan.

Include ultrasound report details (visualization, secondary signs) and numeric WBC value with lab reference range.
If advanced imaging is not pursued after ultrasound, document the clinical rationale and follow-up plan.

Documentation Required

Document inflammatory markers or endoscopy findings for IBD imaging requests

For IBD imaging requests, document inflammatory markers or endoscopy/colonoscopy findings to support MR or CT enterography. Provide the specific marker values and dates.

Acceptable markers: fecal lactoferrin (≥4.0 µg/g), CRP (>0.5 mg/dL), fecal calprotectin (≥50 µg/g).
If imaging is requested prior to endoscopy, document consultation with the endoscopist when applicable.

Documentation Required

Diagnosis of hypertension should be supported by repeated BP measurements and ABPM if used

Diagnosis of pediatric hypertension should be supported by repeated blood pressure measurements (generally ≥3 readings) or ambulatory blood pressure monitoring (ABPM) data when used to establish the diagnosis prior to advanced imaging referrals.

Provide clinic BP readings with dates and percentiles or ABPM download/report if available.
Indicate if initial imaging (Doppler US, CT angiography, or MRA) is being requested for suspected secondary causes.

Documentation Required

Indication and timing documentation — include timing and indication for neonatal/adolescent follow-up imaging

Document indication and timing for neonatal and pediatric follow‑up imaging (e.g., adrenal masses, antenatal hydronephrosis). Adhere to guideline-specified follow-up intervals to support medical necessity.

Neonatal adrenal masses: document initial ultrasound date, interval imaging plan (7–10 day follow-up for adrenal hemorrhage), and any concerning features prompting MRI/CT.
Antenatal hydronephrosis: document prenatal findings, postnatal timing (within 24 hours or after seven days as indicated), and plan for second ultrasound at 4–6 weeks.

Documentation Required

Clinical indication documentation — include presenting signs, labs, and prior imaging for high-risk abdominal conditions

Clinical indication documentation for emergent conditions (intussusception, suspected obstruction, LLQ red flags) must include the presenting signs/symptoms, duration, vital signs/labs, and any prior imaging to support use of CT, MRI, or nuclear studies.

For intussusception: document strong clinical suspicion and ultrasound findings if available; CT or MRI may be used to characterize lead points.
For bowel obstruction: document whether obstruction is high‑grade or intermittent/low‑grade and prior imaging results; MRI preferred when readily available.

Note

Governance and documentation — follow federal/state/contractual benefit rules; in conflict, federal/state/contractual prevails

Governance and documentation: follow federal, state (OAC), and contractual benefit rules when applying this policy. In case of conflict, federal/state/contractual requirements prevail over this guideline.

Check plan‑specific benefit terms before relying solely on these guidelines for coverage decisions.
UnitedHealthcare may use InterQual and other internal policies when InterQual lacks applicable criteria.

Billing Rule

Limited CT restrictions — CPT 76380 not medically necessary for treatment planning

Limited CT restrictions: CPT 76380 (limited or follow‑up CT) is not medically necessary for treatment planning and should not be used to circumvent full diagnostic CT codes. Small additional slices are included in diagnostic CT codes; do not bill 76380 with diagnostic CTs to cover 'extra slices.'

Document the clinical reason for a truly limited study and avoid using 76380 to report routine additional slices.
If full diagnostic interpretation is performed, use the appropriate diagnostic CT code rather than CPT 76380.

Step Therapy

Conservative care before advanced imaging — document prior conservative therapy and response

Conservative care should be attempted and documented before ordering advanced imaging for conditions where clinical improvement on conservative therapy is expected. Imaging is not indicated if it will not affect management.

Document duration and nature of conservative measures and the patient's response prior to requesting advanced imaging when the guideline requires it.
Exceptions include red flags or guideline‑specified indications that bypass conservative‑care prerequisites.

Step Therapy

Stepwise imaging for RUQ pain — ultrasound/HIDA first; MRI/CT only if indicated

Stepwise imaging for RUQ pain: begin with ultrasound and/or HIDA as first‑line; escalate to MRI or CT only when ultrasound/NM is equivocal or when guided by specific clinical criteria.

Ultrasound (CPT 76700) is the initial test for suspected cholecystitis or gallstones; HIDA (CPT 78226/78227) is appropriate when indicated.
If ultrasound/NM is equivocal, MRI Abdomen with and without contrast (CPT 74183) or CT Abdomen with contrast (CPT 74160) is medically necessary.

Step Therapy

Imaging sequence requirement — ultrasound and diuretic renography first-line for obstructive uropathy; escalate to MRU/CT if inconclusive

Imaging sequence requirement: for suspected obstructive uropathy, initial evaluation should use ultrasound (76770/76705) and diuretic renography (78707–78709) as first‑line; MRU or CT should be reserved for inconclusive or escalating cases.

Diuretic renography (CPT 78707–78709) is medically necessary for differentiating obstructive from non‑obstructive dilatation and quantifying renal function.
Magnetic resonance urography (MRU) (CPT 74183 + 72197) or CT Abdomen with contrast (CPT 74160) is medically necessary when ultrasound and renography are inconclusive or when a vascular cause is suspected.

Surveillance Intervals and Repeat Imaging Rules

Repeat imaging only for evidence of progression, recurrence, or if it will affect management

Repeat imaging general ruleRepeat imaging is appropriate only for evidence of progression, recurrence, or when results will affect clinical management; routine repeat imaging without these reasons is not generally necessary.

Pre-operative imaging caveatPre-operative or pre-procedural imaging is not medically necessary if the planned surgery/procedure is not medically necessary.

Avoid duplicate studiesReview prior imaging to avoid duplicate or questionably necessary studies; clinical history and indication should justify repeats.

Surveillance schedule examples — hepatic adenoma, hemangioma/FNH surveillance timing

Hepatic adenoma surveillanceCT Abdomen (74160/74170) or MRI Abdomen (74183) every 6 months for 2 years, then annually to monitor growth and malignant transformation.

Hemangioma / FNH surveillanceHepatic hemangioma: limited ultrasound at 6–12 months; if stable or decreasing, continue US surveillance 6–12 months until 2 years then stop; FNH: MRI (74183) or CT (74160/74170) to confirm, then limited US at 6–12 months and similar 2‑year stop rule if stable.

When to escalateIf lesions increase in size or are not adequately visualized on US, escalate to MRI (74183) or CT (74160/74170) per lesion characteristics.

MRI Abdomen (CPT 74181) or equivalent — Every 12 months

MRI Abdomen (CPT 74181) screening intervalEvery 12 months — recommended screening interval for chronically transfused individuals at risk of hemochromatosis using MRI abdomen without contrast for liver iron evaluation.

Modality/techniqueT2* MRI technique (non-contrast) is established for quantifying organ iron burden; contrast is not necessary.

Concurrent cardiac assessmentMRI Cardiac (CPT 75557) may be used for cardiac iron evaluation; MRI chest (CPT 71550) can be used as a single study to assess both heart and liver when requested.

MRI Abdomen/Cardiac — Every 3 months

MRI Abdomen/Cardiac monitoring intervalEvery 3 months — imaging frequency for treatment response monitoring during active chelation or phlebotomy therapy in transfusion‑associated hemochromatosis.

Applicable studiesMRI Abdomen (74181) for liver iron and MRI Cardiac (75557) for cardiac iron; studies may be scheduled at this interval during active treatment.

Non-contrast techniqueT2* MRI (non-contrast) is used for iron quantification; contrast is unnecessary for this purpose.

Ultrasound surveillance intervals — Every 3-12 months

Ultrasound surveillance interval (general)Every 3–12 months — infants with known hydronephrosis may be followed by ultrasound at intervals within this range until resolution.

Context-specific timingSurveillance interval selected based on severity, clinical course, and presence of obstruction; shorter intervals for concerning changes.

Postoperative follow-upFor obstructive uropathy, postoperative imaging (US and/or diuretic renography) is typically performed at 3–12 months as clinically indicated.

Antenatal hydronephrosis follow-up — Second ultrasound at 4-6 weeks of age

Second postnatal ultrasound timingSecond postnatal ultrasound at 4–6 weeks of age is medically necessary for all infants with antenatal hydronephrosis, even if the initial postnatal ultrasound is normal.

Initial postnatal timing by severityPostnatal US within 24 hours for males with distended bladder or moderate/severe AHN; after seven days for mild prenatal AHN.

Follow-up planSubsequent surveillance with ultrasound every 3–12 months until resolution based on findings.

Ultrasound for intussusception — may be repeated as frequently as daily when indicated

Frequency for repeated US in HPSRepeat limited abdominal ultrasound may be performed as frequently as daily until vomiting resolves or diagnosis is made in infants with suspected hypertrophic pyloric stenosis.

Initial modalityUS Abdomen, limited (CPT 76705) is the initial medically necessary study for persistent projectile non‑bilious vomiting in infants.

Clinical noteRepeat imaging daily is appropriate when initial studies are nondiagnostic and clinical suspicion remains high.

Prior Authorization — When Required and How to Document

Note

Contrast Use and Safety Considerations

Note

Excluded and Investigational Services

MRI utilizing Xenon Xe 129 (CPT C9791) is investigational/experimental and excluded. Additionally, 3D rendering codes (CPT 76376, 76377) require documented physician concurrent supervision and are not allowed for routine 2‑D reformatting; billing them without meeting those requirements or when combined with prohibited procedures may result in denial.

3D rendering (CPT 76376, 76377) must be limited to situations that require true volumetric post‑processing with physician participation. They must not be billed for routine 2‑D reformatting and should not be reported in combination with the procedural/modality pairings listed in the guideline; prior authorization for these codes may be required even if the parent study does not require authorization.

Advanced imaging studies performed as screening in asymptomatic individuals are not supported by these guidelines and are not considered medically necessary unless a condition‑specific section states otherwise. Requests for whole‑body CT or similar screening scans in asymptomatic patients will be denied as a non‑covered service.

Imaging for asymptomatic microscopic hematuria in an otherwise well child without proteinuria is not medically necessary. Advanced cross‑sectional imaging should be reserved for cases with gross hematuria, hematuria with proteinuria, pain, or trauma as described in the hematuria section.

Background and Scope

These evidence‑based guidelines evaluate advanced imaging modalities (nuclear medicine, ultrasound, CT, MRI, PET) and related procedures for pediatric abdominal conditions. The guidance is intended to support appropriate selection of imaging based on clinical presentation, emphasize ultrasound as the initial modality in most pediatric abdominal evaluations, and to promote safety by limiting investigational techniques and unnecessary screening studies.

Guideline scope definition and applicability

Scope statementEvidence‑based proprietary clinical guidelines evaluating advanced imaging and procedures (NM, US, CT, MRI, PET) for pediatric abdominal conditions; based on national/international society guidance and peer‑reviewed literature.

ApplicabilityApplies to UnitedHealthcare members in Ohio and to providers requesting imaging and utilization reviewers making medical necessity determinations.

Clinical judgmentGuidelines are not intended to replace physician judgment; clinicians may override guidance when appropriate for individual patients.

Key Definitions and Terminology

Investigational/Experimental definition

Investigational/Experimental definitionStudies, treatments, procedures, or devices lacking sufficient supporting evidence, clinical utility, or collective opinion of support are considered investigational/experimental (e.g., MRI utilizing Xenon Xe 129 CPT C9791).

Evidence requiredSupporting evidence includes peer‑reviewed literature, randomized trials, cohort studies with sufficient power, or consensus from specialty societies.

Implication for coverageInvestigational/experimental services are excluded from guideline‑supported imaging and may not be covered.

Standard imaging definition

Standard imaging definition'Standard' or 'conventional' imaging includes plain film, CT, MRI, or ultrasound typically used in initial and subsequent evaluations.

Role in pathwayStandard imaging often precedes advanced imaging; further studies are performed when initial studies are inconclusive or insufficient to answer the clinical question.

Contrast considerationAppropriate use and level of contrast is determined by condition‑specific evidence and indications.

Concurrent supervision (3D rendering) definition

Concurrent supervision (3D rendering)Defined as active physician participation in and monitoring of the 3D reconstruction including design of anatomic region, selection of tissue/structures to display, selection of images/cine loops to archive, and monitoring/adjustment of the 3D work product.

Code distinctionsCPT 76376 reports 3D rendering not requiring an independent workstation; CPT 76377 reports 3D rendering requiring independent workstation post‑processing.

Billing constraints3D rendering codes should not be used for routine 2D reformatting; prior authorization for 3D codes may be required even if parent study does not require authorization.

Whole-body MRI (WBMRI) definition and reporting guidance

Whole‑body MRI definitionWhole‑body MRI (WBMRI) covers multiple body regions without standardized CPT codes and is reportable only with unlisted MRI code CPT 76498; generally not supported except for select cancer predisposition syndromes and some specific indications.

Coding guidanceDo not report WBMRI using multiple regional MRI codes; use CPT 76498 for WBMRI reporting when clinically appropriate per guideline exceptions.

Indication limitsInterval WBMRI may be recommended for specific cancer predisposition syndromes; otherwise WBMRI lacks standardization and outcome evidence.

MR Urography (MRU) definition (CPT 74183 & 72197)

MR Urography definition (codes)MR Urography (MRU) uses MRI Abdomen without and with contrast (CPT 74183) together with pelvic sequences (CPT 72197) to evaluate the urinary tract; MRU is not a first‑line test for routine UTI but is medically necessary for investigation of a dilated upper urinary tract or complex anatomy.

Clinical considerationsMRU may require sedation in young children and can quantify renal function; it is indicated when ultrasound and diuretic renography are inconclusive.

Coding noteReport MRU using CPT 74183 with CPT 72197 per guideline examples when appropriate.

MR Enterography (MRE) definition

MR Enterography definitionMR Enterography (MRE) is an advanced MRI technique (CPT 74183 or CPT 74181 with pelvic sequences CPT 72197 or 72195) preferred over CT enterography to evaluate small bowel inflammation and complications in pediatric IBD.

Preferred modalityMRE is generally preferred to avoid ionizing radiation in children; CT Enterography (CPT 74177) is an alternative when indicated or requested.

Coding combinationMRE is reported using abdomen MRI codes combined with pelvic MRI sequences as specified in the guideline (74183 or 74181 + 72197/72195).

Transient Elastography (VCTE) definition (CPT 91200)

Transient Elastography (VCTE) definition and codeVibration‑controlled transient elastography (VCTE, e.g., FibroScan) is a noninvasive ultrasound‑based elastography used as the initial imaging modality for staging liver fibrosis (CPT 91200).

Role in pathwayTE is first‑line for initial staging of suspected chronic liver disease; MRE reserved for TE failure, BMI ≥30, or discordant results.

Coding noteUse CPT 91200 to report transient elastography / VCTE per guideline.

Magnetic Resonance Elastography (MRE) definition (CPT 76391)

Magnetic Resonance Elastography (MRE) definition (CPT 76391)MRE (CPT 76391) is an MRI‑based elastography technique indicated when transient elastography fails, in individuals with BMI ≥30, or when TE results conflict with the clinical picture.

IndicationsReserved for cases where TE is nondiagnostic or where body habitus (BMI ≥30) reduces TE accuracy or when clinical discordance exists.

Coding implicationReport MRE with CPT 76391 when medically necessary per listed criteria.

T2* MRI definition for iron burden quantification

T2* MRI definition for iron quantificationT2* MRI is an MRI technique established for quantifying organ iron burden in transfusion‑associated hemochromatosis; contrast is not necessary for this evaluation.

ApplicationUsed to assess hepatic and cardiac iron burden (MRI abdomen CPT 74181 and MRI cardiac CPT 75557); MRI chest CPT 71550 may evaluate both heart and liver when requested as a single study.

Surveillance/monitoring intervalsScreening annually and monitoring every 3 months during active treatment as specified in the guideline.

Policy Revision History

2026-02-03Policy effective dateLatest

Policy version V1.0.2026 became effective February 3, 2026.

2025-11-06Annual update

Annual evidence-based updates applied to the guideline (listed in policy history).

2025-05-01Annual update

Annual evidence-based updates applied to the guideline (listed in policy history).

2024-07-01Interim update

Interim evidence-based updates applied to the guideline (listed in policy history).

2024-02-01Annual update

Annual evidence-based updates applied to the guideline (listed in policy history).

Policy Summary

PayerUnitedHealthcare

PolicyPediatric Abdomen Imaging Guidelines (Ohio)

Policy CodePolicy CSRAD015OH.E

Change TypeNo material changes

Effective DateFebruary 3, 2026

Next Review DateN/A

Key ActionSubmit pertinent clinical records and documentation to establish medical necessity when requesting advanced imaging or other designated procedures.

SourceLink

On This Page

If hematuria is present, follow the Hematuria (PEDAB-7) guideline for imaging selection and indication for CT, ultrasound, or nuclear studies as appropriate.

Nuclear kidney imaging (CPT 78707, CPT 78708, CPT 78709, or CPT 78803) is medically necessary for evaluation of recurrent flank pain when CT and ultrasound are non-diagnostic, or for suspected obstructive uropathy.