GENERAL INFORMATION 

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy

• Abdomen CT alone should ONLY be approved when disease process is suspected to be limited to the abdomen. Abdomen/Pelvis CT (CPT Codes: 74176, 74177, 74178) is the correct study when the indication(s) include both the abdomen AND pelvis, such as CTU (CT Urography), CTE (CT Enterography), acute abdominal pain, widespread inflammatory disease, or neoplasm.
• When separate requests for CT abdomen and CT Pelvis are encountered for processes involving both the abdomen and pelvis, they need to be resubmitted as a single Abdomen/Pelvis CT (to avoid unbundling; CPT codes 74176, 74177, 74178). Otherwise, the exam should be limited to the appropriate area (i.e., Abdomen OR Pelvis) which includes the specific organ, area of known disease/abnormality, or the area of concern.

INDICATIONS FOR ABDOMEN CT
Organ Specific Imaging
Adrenal¹

• Adrenal mass < 4 cm incidentally discovered with benign characteristics (homogenous, regular borders, HU < 10), one follow-up at 6 months then annually x 2 years (no further imaging if stable)
• If adrenal mass ≥ 4 cm and no diagnosis of cancer, can approve for either pre- operative planning OR if surgery is not done, can repeat imaging in 6 – 12 months then as clinically indicated (if there is known malignancy, biopsy is typically the next step rather than surveillance imaging)
• For follow up of known adrenal mass when a change in tumor is suspected by either imaging, laboratory evaluation and/or symptoms
• See Genetic Syndromes and Rare Diseases for additional screening indications

Liver

• Indeterminate liver lesion seen on prior imaging³
• For evaluation of rising AFP (requires a ≥ 7 ng/mL increased in AFP per month) in patients at high risk for HCC (known cirrhosis and/or chronic hepatitis B, see Background for additional risk categories)⁴
• For screening in patients at high risk for HCC (see above) every 6 months when prior ultrasound is insufficient to evaluate the liver due to steatosis/fatty liver or nodular liver
  • The finding of steatosis/fatty liver and/or nodular liver alone on an ultrasound report is insufficient for approval; the report must specify that those findings prevent adequate visualization of the liver by ultrasound
• For jaundice or abnormal liver function tests after equivocal or abnormal ultrasound^5,6
• For follow-up of suspected hepatocellular adenomas every 6 – 12 months for two years, then annually (sooner if change was noted on last imaging study)^7,8
• For surveillance of patients with primary sclerosing cholangitis every 6 – 12 months after the age of 20 when MRI is contraindicated or cannot be performed⁹
• For follow-up of focal nodular hyperplasia (FNH), repeat imaging in 6 – 12 months to ensure stability. Additional imaging beyond that is needed only if atypical features or diagnosis is still in question⁷
• See Genetic Syndromes and Rare Diseases for additional screening indications

Pancreas

• Pancreatic cystic lesion found on initial imaging, approve for initial characterization of lesion¹⁰
• Follow-up for pancreatic cyst as below AND MRI is contraindicated:^10,11
  • Incidental and asymptomatic cysts < 1.5 cm, AND:
    • Age < 65, image annually x 5 years, then every 2 years if stable
    • Age 65 – 79, imaging every 2 years x 5, then stop if stable
  • Cysts 1.5 – 1.9 cm with main pancreatic duct communication (MPD), image annually x 5 years, then every 2 years x 2, stop if stable at year 9.
  • Cysts 2.0 – 2.5 cm with MPD communication, image every 6 months x 4, then annually x 2, then every 2 years x 3, stop if stable at year 10.
  • Cysts 1.5 – 2.5 cm with NO MPD communication (or cannot be determined), image every 6 mos. x 4, then annually x 2 then every 2 years x 3, stop if stable at year 10.
  • Cyst > 2.5 cm on surveillance (i.e., intervention has not been chosen), image every 6 mos. x 4, then annually x 2 years, then every 2 years x 3. Stop if stable at year 10.
  • Patients > 80 years of age at presentation are imaged less frequently: image every 2 years x 2, stop if stable at year 4 (intervals are the same regardless of size if surveillance chosen)
  • Growth or suspicious change on a surveillance imaging scan may warrant more frequent surveillance
• Localization of a functional pancreatic tumor, see Background (endocrine) once diagnosis is confirmed (or highly suspected)¹⁰
• See Genetic Syndromes and Rare Diseases for additional screening indications

Renal

• Surveillance of known angiomyolipoma (AML):

  • Size > 4 cm: Annually

  • Size 3 – 4 cm: Every 2 years

    • NOTE: if < 3 cm monitoring with advanced imaging (CT/MRI) is not needed unless the pt has known Tuberous Sclerosis^15,16,17

• AML (any size) in an individual with known tuberous sclerosis (TSC):¹⁸ Annually

• Post-embolization imaging for AML:

  • One study within the first 6 months, then

  • At one-year post-embolization,

    • Further imaging beyond one year if stable reverts to the above imaging frequency for monitoring (based on size and/or presence of known TSC)^19,20

• Polycystic Kidney Disease²¹

  • To assess total kidney volume (TKV) prior to treatment when MR is contraindicated or cannot be performed

  • To monitor total kidney volume annually if PRO-PKD score is ≥ 4 when MR is contraindicated or cannot be performed

• See Genetic Syndromes and Rare Diseases for additional screening indications

Spleen

●    Incidental findings of the spleen that are indeterminate on other imaging
●    See Genetic Syndromes and Rare Diseases for additional screening indications

Evaluation of Iron Overload (22,23)

• Initial evaluation of liver iron in Hemochromatosis diagnosed in lieu of liver biopsy when MRI is contraindicated or cannot be performed
• Annual evaluation for high-risk patients: transfusion-dependent thalassemia major, sickle cell disease, and other congenital anemias when ultrasound is insufficient and when MRI is contraindicated or cannot be performed

Evaluation of Suspected Infection or Inflammatory Disease(24,25)

Pancreatitis: Suspected and Known

• Initial imaging for suspected acute pancreatitis due to epigastric pain with elevated amylase and/or lipase:
  • For mild presentation when symptom improvement is not seen after 72 hours of treatment and either:
    • Ultrasound has been performed and did not show an abnormality such as gallstones, dilated bile duct
    • Ultrasound suggests complications (such as fluid collection)
  • For severe presentation (such as fever, elevated WBC)
  • For a decline in clinical status and/or suspected complication
• History of pancreatitis, including pancreatic pseudocyst, with abdominal pain suspicious for worsening or re-exacerbation
• Known necrotizing pancreatitis requiring follow-up
• In patients > 40 years of age who have pancreatitis with no identifiable cause, CT is indicated to exclude neoplasm

Infection and Inflammation Limited to the Abdomen

• Any known infection that is clinically suspected to have created an abscess limited to the abdomen (If location unclear or unknown, CT Abdomen/Pelvis)
• Any history of fistula limited to the abdomen that requires re-evaluation or is suspected to have recurred
• Abnormal fluid collection limited to the abdomen seen on prior imaging that needs follow-up evaluation

Evaluation of Suspected/Known Hernia (26)

Other Indications

• Right upper quadrant pain for suspected biliary disease with negative or equivocal ultrasound⁽²⁸⁾
• Evaluation of known or suspected non-aortic vascular disease (such as aneurysm, hematomas) after inconclusive ultrasound AND CTA/MRA is contraindicated or cannot be performed
• Prior to solid organ transplantation
• For abnormal incidental abdominal lymph nodes when follow-up is recommended based on prior imaging and pelvic imaging is not needed(initial 3-month follow-up)⁽²⁹⁾

Follow-Up of Known Cancer (30,31)
Initial Staging

• For initial staging of the majority of cancers, CT Abdomen and Pelvis is the more appropriate study (see CG_068). For Hepatocellular Carcinoma, Esophageal Carcinoma and Malignancies where liver metastases are suspected and pelvis imaging is not needed, CT Abdomen can be considered.

Restaging

• Abdomen CT is indicated for restaging during active treatment (every 2 – 3 cycles of chemo or immunotherapy, following radiation and/or after surgery) for the following malignancies:
  • Esophageal and Esophagogastric Junction Cancers
  • Primary Liver Cancers

Surveillance

• Esophageal and esophagogastric junction cancers every 3 months for 2 years, then annually for 5 years
• Hepatocellular carcinoma every 3 months for 2 years, then every 6 months indefinitely⁴
• Renal Cell Carcinoma baseline within 3-6 months, then every 3 – 6 months for 3 years, then annually for 2 years then as clinically indicated

• When a cancer is not listed above, Abdomen CT is not routinely a part of surveillance for that cancer in an asymptomatic patient. Please see CG_068 Abdomen and Pelvis CT for additional indications. For Abdomen CT NOT including the pelvis, there would need to be concern for recurrence in the liver (i.e. liver metastases) to consider Abdomen CT.

Pre-Operative Planning

• For abdominal surgery or procedure
• Pre-procedure for transjugular intrahepatic portosystemic shunt (TIPS)³²

Post-Operative/Procedural Evaluation

• Follow-up of known or suspected post-operative complication involving only the abdomen
• A follow-up study to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed

Genetic Syndromes and Rare Diseases
Surveillance Screening Abdomen CT for the Following KNOWN Genetic Syndromes

• HLRCC (hereditary leiomyomatosis and renal cell cancer) annually starting at age 8³³
• HPRCC (hereditary papillary renal carcinoma) annually starting at age 30³³
• Multiple Endocrine Neoplasia type 1 (MEN1): annually^37,38
• PGL/PCC (Hereditary Paraganglioma/Pheochromocytoma syndromes or SDHx mutations): every 2 years IF whole body MRI (unlisted MRI CPT 76498) not available³⁹ (see Unlisted Studies Evolent_CG_063)³³
• PRSS1 (Hereditary Pancreatitis; including PRSS1, SPINK1 and other hereditary pancreatitis genes): Annually starting 20 years after onset of pancreatitis, or at age 40 years, whichever is earlier when MRI is contraindicated or cannot be performed³⁵
• SKT11 variant (including Peutz-Jeghers): Annually starting at age 30 (or 10 years younger than the earliest pancreatic cancer diagnosis in the family, whichever is earlier) when MRI is contraindicated or cannot be performed³⁵
• TSC (tuberous sclerosis complex)³³
  • TSC without known AML: every 3 years starting at age 12
  • TSC with known AML: annually
• Von Hippel Lindau (VHL) every 2 years starting at age 15^33,37
• Other variants AND family history of pancreatic cancer as detailed below: Starting at age 50 (or 10 years younger than the earliest pancreatic cancer diagnosis in the family, whichever is earlier) when MRI is contraindicated or cannot be performed for the following:
  • ≥ 1 first- or second-degree relative with history of pancreatic cancer from the same side of the family as the identified variant AND known mutation in other pancreatic susceptibility genes (ATM, BRCA1, BRCA2, MLH1 (Lynch), MSH2, MSH6, EPCAM, PALB2, TP53): Annually when MRI is contraindicated or cannot be performed
• For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance

Surveillance Screening Based on Family History

To screen for pancreatic cancer in patients with no identified mutation listed above AND the following family history when MRI is contraindicated or cannot be performed:

• ≥ 2 first-degree relatives with a history of pancreatic cancer from the same side of the family: Annually
• ≥ 3 first- and/or second-degree relatives with a history of pancreatic cancer from the same side of the family: Annually

Special Note

• For syndromes for which imaging starts in the pediatric age group, MRI is preferred to limit lifetime radiation exposure. When CT is requested instead of MRI, a contraindication or relative contraindication to MRI should be provided such as contraindication to sedation if sedation is required for MRI.

Combination Studies
Abdomen CT and Abdomen CTA

• When needed for clarification of vascular invasion from tumor (including renal vein thrombosis)

Abdomen CT (or MRI) and Abdomen CTA (or MRA) and PET

• Prior to Y90 treatment

Abdomen MRA and Abdomen MRI or CT

• When needed for clarification of vascular invasion from tumor (including suspected renal vein thrombosis)

Combination Studies for Malignancy for Initial Staging or Restaging
Unless otherwise specified in this guideline, indication for combination studies for malignancy for initial staging or restaging:

• Concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Abdomen, Brain, Chest, Neck, Pelvis, Cervical Spine, Thoracic Spine or Lumbar Spine.

Further Evaluation of Indeterminate Findings on Prior Imaging
Unless follow up is otherwise specified within the guideline;

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification AND finding is expected to be limited to the abdomen
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam)

Background
Adrenal and Neuroendocrine Tumors
Biochemical Evaluation
Laboratory evaluation prior to imaging when neuroendocrine and hormonally active tumors are suspected, the required laboratory evaluation prior to advanced imaging is dependent on the tumor type that is suspected. The following list describes suspected syndrome/tumor and typical laboratory evaluation in parenthesis:

GI Carcinoid (24-hour urine or plasma 5-HIAA), Lung/Thymus Carcinoid (24-hour urine or plasma 5-HIAA AND one of the following: overnight dexamethasone suppression test, 2 – 3 midnight salivary cortisols, 24-hour urinary free cortisol), PPoma (serum pancreatic polypeptide), Insulinoma (serum insulin, pro-insulin and C-peptide all drawn during a period of hypoglycemia (i.e., 72 hour fast)), VIPoma (serum VIP), glucagonoma (serum glucagon), gastrinoma (serum gastrin), somatostatinoma (serum somatostatin), pheochromocytoma/paraganglioma (plasma free or 24-hour urine fractionated metanephrines and normetanephrines +/- serum or urine catecholamines), pituitary tumor (serum IGF-1, prolactin, LH/FSH, alpha subunits, TSH and ONE of the following: overnight dexamethasone suppression test, 2 – 3 midnight salivary cortisols, 24-hour urinary free cortisol), primary hyperaldosteronism (suppressed renin/renin activity in association with elevated plasma aldosterone (> 10 ng/dL) and confirmatory testing if positive), adrenocortical carcinoma (testosterone, DHEA-S AND complete evaluation for hypercortisolemia or primary aldosteronism).³⁷

If Cushing’s (hypercortisolemia) is suspected, typical labs include a plasma ACTH AND one or more of the following: overnight dexamethasone suppression test, 2 – 3 midnight salivary cortisols, OR 24-hour urinary free cortisol. The results of the suppression test then indicate whether brain imaging is needed (pituitary source) OR chest and abdominal imaging is needed (CXR + Adrenal CT/MRI). ACTH > 20 after suppression > 20 is suggestive of Cushing’s Disease and Pituitary MRI is indicated. ACTH after suppression < 5 is suggestive of Cushing’s Syndrome and CXR + Adrenal CT/MRI is indicated.(40) If indeterminate, a CRH or desmopressin test is then done. If there is no ACTH suppression with CRH/desmopressin, then adrenal imaging is indicated.

Liver
Screening for Hepatocellular Carcinoma (HCC)
AASLD (American Association for the Study of Liver Diseases) recommends screening for HCC with ultrasound every 6 months for patients with hepatitis C and B.⁴¹ Advanced imaging is recommended when the AFP is rising, regardless of ultrasound results. The main risk factors for HCC are cirrhosis and Hepatitis B. Additional populations for which there is a benefit to surveillance for HCC include: Asian males Hepatitis B carriers ≥ 40 y, Asian female Hepatitis B carriers ≥ 50 y, Hepatitis B carriers with + family history of HCC and African and/or North American blacks with hepatitis B.^4,42

Kidney
PRO-PKD Score^43,44
The PRO-PDK score is to assess prognosis in ADPKD, risk scoring system is on the basis of PKD mutation and clinical parameters.

Contraindications and Preferred Studies

• Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester)
• Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non- compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds weight limit/dimensions of MRI machine
• Abdominal ultrasound may be limited by the body habitus and BMI (Body Mass Index) and when the abdominal wall thickness impairs visualization of the intra-abdominal contents by ultrasound, CT can be considered without prior ultrasound provided the other guideline criteria for that indication are met

References

33. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Kidney Cancer V3.2024. National Comprehensive Cancer Network®. 2024; 1,23.
34. Shuman C, Kalish J, Weksberg R. Beckwith-Wiedemann Syndrome. 2000 Mar 3 [Updated 2023 Sep 21]. GeneReviews® [Internet]. 2023.
35. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic V3.2024. National Comprehensive Cancer Network®. 2024; v3.2024.
36. Hughes D, Pastores G. Gaucher Disease. 2000 Jul 27 [Updated 2023 Dec 7]. GeneReviews® [Internet]. 2023.
37. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Neuroendocrine and Adrenal Tumors. February 8, 2033; Version 2.2022: 70-71.
38. Kamilaris C D C, Stratakis C A. Multiple Endocrine Neoplasia Type 1 (MEN1): An Update and the Significance of Early Genetic and Clinical Diagnosis. Frontiers in endocrinology. 2019; 10: 339. 10.3389/fendo.2019.00339.
39. Else T, Greenberg S, Fishbein L. Hereditary Paraganglioma-Pheochromocytoma Syndromes. 2008 May 21 [Updated 2023 Sep 21]. GeneReviews® [Internet]. 2023.
40. Consult A. Adrenal Hyperfunction (Cushing Syndrome) Testing Algorithm. 2021; 2023:
41. Lichtenstein G, Loftus E, Isaacs K, Regueiro M, Gerson L. ACG Clinical Guideline: Management of Crohn’s Disease in Adults. Am J Gastroenterol. Apr 2018; 113: 481-517. 10.1038/ajg.2018.27.
42. Marrero J A, Ahn J, Reddy R K. ACG Clinical Guideline: The Diagnosis and Management of Focal Liver Lesions. Official journal of the American College of Gastroenterology | ACG. 2014; 109: 1328- 1347. 10.1038/ajg.2014.213.
43. Cornec-Le Gall E, Audrézet M, Rousseau A, Hourmant M, Renaudineau E et al. The PROPKD Score: A New Algorithm to Predict Renal Survival in Autosomal Dominant Polycystic Kidney Disease. Journal of the American Society of Nephrology. 2016; 27: 942-51. 10.1681/ASN.2015010016.
44. Gansevoort R T, Arici M, Benzing T, Birn H, Capasso G et al. Recommendations for the use of tolvaptan in autosomal dominant polycystic kidney disease: a position statement on behalf of the ERA-EDTA Working Groups on Inherited Kidney Disorders and European Renal Best Practice. Nephrology, dialysis, transplantation. 2016; 31: 337-48. 10.1093/ndt/gfv456.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community,  and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved"  

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