Description
Abdominal magnetic resonance imaging (MRI) generates images of the organs and structures within the abdomen without the use of ionizing radiation.

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 
IMPORTANT NOTE: A single authorization for CPT codes 74181, 74182, 74183, S8037 covers imaging of the biliary tree and its attached organs, i.e., the liver, gallbladder (GB), and pancreas. These same codes also cover MRI abdomen, magnetic resonance enterography (MRE), and magnetic resonance urography (MRU). Multiple authorizations are not typically required. When both magnetic resonance cholangiopancreatography (MRCP) and MRI abdomen are requested, documentation requires a medical reason clearly indicating why both are needed, i.e., that meets guidelines for imaging of bowel, kidneys, or areas other than liver, pancreas, GB, and biliary tree as well.

Note: There are no MRI abdomen/pelvis combo (comparable to a CT abdomen/pelvis) such that if imaging of both the abdomen and pelvis are indicated, two separate exams (and authorization) are required (i.e., MRI abdomen and MRI pelvis)

INDICATIONS FOR ABDOMEN MRI
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)
• 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
• 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
• 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
• Jaundice or abnormal liver function tests after equivocal or abnormal ultrasound^5,6
• Follow-up of suspected hepatocellular adenomas every 6 months for 2 years, then annually (sooner if change was noted on last imaging study)^7,8
• Surveillance of patients with primary sclerosing cholangitis, every 6 months after the age of 20 (MRI and MRCP preferred over CT)⁹
• 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 question⁸
• 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:^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

• • • • NOTE: Bosniak I and II cysts need no further follow-up. (Bosniak I cysts are simple non-enhancing cysts with thin walls, no septa, calcifications or solid components, Bosniak II cysts may contain thin septa, small or fine calcification, minimal enhancement and/or hyperdense and < 3 cm)¹⁴
• 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
      • If stable, further imaging reverts to the above imaging frequency for monitoring (based on size and/or presence of known TSC)^19,20
• MRU (may also approve MR pelvis for MR urography) when ultrasound is inconclusive, and CT (CTU) cannot be done or is inconclusive and MRI is recommended
• Polycystic Kidney Disease²¹
  • To assess total kidney volume (TKV) at diagnosis and prior to treatment
    • To monitor total kidney volume annually if PRO-PKD score is ≥ 4²²
• See Genetic Syndromes and Rare Diseases for additional indications

Spleen

• Incidental findings of the spleen that are indeterminate on ultrasound or CT imaging²³
• See Genetic Syndromes and Rare Diseases for additional indications

Evaluation of Iron Overload^24,25

• Initial evaluation of liver iron in Hemochromatosis diagnosed in lieu of liver biopsy
• Annual evaluation for high-risk patients: transfusion-dependent thalassemia major, sickle cell disease, and other congenital anemias

Inflammatory Bowel Disease^26,27

• For evaluation of Inflammatory Bowel Disease (IBD) such as Crohn’s or Ulcerative Colitis (includes MR Enterography)
• • For suspected inflammatory bowel disease after complete work up including physical exam, labs, and recent colonoscopy
  • Known inflammatory bowel disease with recurrence or worsening signs/symptoms requiring re-evaluation or for monitoring therapy

Evaluation of Inflammation and Infection^28,29
Fistula

• For history of fistula in the abdomen that requires re-evaluation or is suspected to have recurred (MRI Preferred)

Known or Suspected Infection When CT is Contraindicated or Cannot Be Performed

• Any known infection that is clinically suspected to have created an abscess in the abdomen
• Abnormal fluid collection limited to the abdomen seen on prior imaging that needs follow-up evaluation
• Suspected peritonitis when abdominal pain and tenderness to palpation are present, and at LEAST one of the following:
  • Rebound, guarding or rigid abdomen, OR
  • Severe tenderness to palpation over the entire abdomen
• Complications of diverticulitis (diagnosed either clinically or by imaging) with severe abdominal pain or severe tenderness or mass, not responding to antibiotic treatment)

Other Indications for Abdominal MRI³⁰
For any of the following:

• To locate a pheochromocytoma once there is clear biochemical evidence (See Background)³¹
• Prior to liver transplantation (MRI and MRCP), may repeat studies immediately prior to transplantation with known HCC, PSC, or cholangiocarcinoma
• Prior to solid organ transplantation

For Any of the Following When CT Is Inconclusive or When CT Is Contraindicated or Cannot Be Performed

• Persistent abdominal/pelvic pain not explained by previous imaging
• Suspected or known hernia and either:
  • Occult, spigelian, incisional or epigastric hernia when physical exam and prior imaging (Ultrasound AND CT) is non-diagnostic or equivocal and limited to the abdomen OR
  • Suspected incarceration or strangulation based on physical exam (guarding, rebound) or prior imaging
• For fever of unknown origin (temperature of ≥ 101 degrees for a minimum of 3 weeks) after standard diagnostic tests are negative (see Background)
• Any B-symptoms of fevers more than 101^◦ F, drenching night sweats, or unexplained weight loss of more than 10% of body weight over 6 months with documented concern for lymphoma/malignancy³²
• Weight loss:
  • Clinically significant unintentional weight loss i.e., ≥ 5% of body weight in less than 12 months (or ≥ 2% in one month), with signs or symptoms suggestive of an abdominal cause (see Background) OR
  • Ongoing unexplained clinically significant weight loss i.e., ≥ 5% of body weight in less than 12 months (or ≥ 2% in one month)³³ after initial workup (see Background) has been completed, no cause identified, and second visit documenting further decline in weight³⁴
• Suspected or known retroperitoneal fibrosis after complete workup and ultrasound to determine extent of disease³⁵
• Suspected paraneoplastic syndrome (including dermatomyositis) with high suspicion of abdominal malignancy and appropriate workup has been done (see Background for details)
• Diffuse, unexplained lower extremity edema with negative or inconclusive ultrasound³⁶
• Suspected May-Thurner syndrome (CTV/MRV preferred)³⁷
• Further evaluation of a new onset or non-reducible varicocele³⁸
• Prior to Bone Marrow Transplant (BMT)^39,40
• Follow-up of abnormal lymph nodes with no prior history of malignancy
  • Follow-up imaging at 3 months⁴¹

Indications for MRCP^42,43

• To confirm choledocholithiasis in patients in the acute setting after ultrasound has been completed
• Suspected acute pancreatitis with atypical signs and symptoms, including equivocal amylase and lipase and diagnosis other than pancreatitis may be possible. (MRCP and CT/MRI may be ordered simultaneously in this setting and may be approved)
• Pancreatitis by history (greater than 4 weeks), (including pancreatic pseudocyst) with continued pain suspicious for worsening, or re-exacerbation. (MRCP and CT/MRI may be ordered simultaneously in this setting and may be approved)
• Evaluation of suspected congenital anomaly of the pancreaticobiliary tract, e.g., aberrant ducts, pancreas divisum or related complications
• Suspected choledochal cyst after ultrasound has been done
• Long-term postoperative surveillance for patients with history of choledochal cyst
• Post-surgical biliary anatomy and complications when ERCP is not possible or contraindicated
• Assessment of benign or malignant biliary strictures
• Evaluation of persistent symptoms when abnormalities are identified on other imaging (e.g., ultrasound, CT, or MRI)
• Evaluation of abnormality related to the pancreatic or biliary tree based on symptoms or laboratory findings and initial imaging has been performed or is contraindicated (e.g., renal failure prevents contrast CT or body habitus limits US)
• Evaluation of pancreatobiliary disease in pregnant patients after ultrasound has been done
• Prior to liver transplantation, may repeat studies immediately prior to transplantation with known HCC, PSC, or cholangiocarcinoma

Follow-Up of Known Cancer⁴⁴
Initial Staging

• Abdomen MRI is indicated when there are indeterminate findings on initial staging (such as for suspected liver metastases) imaging in need further evaluation with MRI.
• For the following malignancies, Abdomen MRI is indicated for initial staging:
  • Biliary tract cancers
  • Primary liver cancers
  • Uveal melanoma

Restaging

• Abdomen MRI 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:
  • Breast cancer when there are suspected or known liver metastases
  • Colon cancer when there are suspected or known liver metastases
  • Primary liver cancers
  • Neuroendocrine tumors when there are suspected or known liver metastases
  • Pancreatic cancer
  • Uveal melanoma
• For further evaluation of known liver metastases including prior to liver directed therapy or to assess treatment response
• MRCP is indicated for restaging during active treatment (every 2-3 cycles of chemo or immunotherapy, following radiation and/or after surgery) for the following:
  • Biliary tract cancers (ampullary adenocarcinoma, cholangiocarcinomas and gallbladder cancer)

Surveillance
Abdomen MRI is indicated during surveillance for the following malignancies at the intervals defined below:

• Breast Cancer every 3-6 months when there are suspected or known liver metastases⁴⁵
• Colon Cancer every 3-6 months when there are suspected or known liver metastases⁴⁶
• Hepatocellular Carcinoma every 3-6 months for 2 years then every 6 months indefinitely⁴
• Pancreatic Cancer every 3-6 months for 2 years then every 6-12 months as clinically indicated⁴⁷
• Uveal Melanoma: every 6-12 months for 10 years then as clinically indicated⁴⁸
• When CT is contraindicated or cannot be performed AND the medical necessity criteria have been met (see CG 068 Abd Pelvis CT) for that malignancy, Abdomen MRI can be used during surveillance instead of CT.

Pre-Operative Evaluation

• For abdominal surgery or procedure

Post-Operative/Procedural Evaluation⁴⁹
When not otherwise addressed in the guideline

• Follow-up of known or suspected post-operative complication (within 6 months) 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 MRI for the following KNOWN Genetic Syndromes

• 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 earlier⁴⁷
• 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)⁴⁷
• TSC (tuberous sclerosis complex)⁵⁰
  • 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 15^50,54
• For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance.

Screening Based on KNOWN Genetic Syndrome in combination With Family History:

• 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) 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

Surveillance Screening Based on Family History

• To screen for pancreatic cancer in patients with no identified mutation listed above

AND the following family history:

• • ≥ 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

Combination Studies
Abdomen MRA and Abdomen MRI or CT

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

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

• Prior to Y90 treatment

Abdomen MRI and MR Elastography

• MRI Abdomen can be used for HCC screening and MR elastography can be used to stage hepatic fibrosis. While each indication requires an insufficient ultrasound, that ultrasound needs to be insufficient for only one of the two indications to meet medical necessity for both studies

Abdomen/Pelvis MRI

• As a dedicated CPT code does not exists for Abdomen and Pelvis MRI (unlike CT), when a disease process is reasonably expected to involve both the abdomen and pelvis AND the guideline criteria have been met, two separate authorizations are required: Abdomen MRI (CPT 74181, 74182, 74183) and pelvis MRI (CPT 72195, 72196, 72197).

Brain/Cervical/Thoracic/Lumbar/Abdomen MRI

• Von Hippel Lindau (VHL) every 2 years starting at age 15⁵⁷

Chest CT and Brain/Abdomen/Pelvis MRI

• Multiple Endocrine Neoplasia Syndrome Type 1 (MEN-1)
  • Chest/Abdomen/Pelvis annually
  • Brain/Chest/Abdomen/Pelvis every 3 years

Neck/Abdomen/Pelvis MRI and Chest CT

• PGL/PCC (Hereditary Paraganglioma/Pheochromocytoma syndromes or SDHx mutations): every 2 years IF whole body MRI (unlisted MRI CPT 76498) NOT available ⁽⁵⁶⁾ (see Unlisted Studies Evolent_CG_063)⁽⁵⁰⁾

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
• 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)

Rationale
Adrenal and Neuroendocrine
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).⁵⁴

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 +/- CXR is indicated. ACTH after suppression < 5 is suggestive of Cushing’s Syndrome and CXR + Adrenal CT/MRI is indicated.(58) If indeterminate, a CRH or desmopressin test is then done. If there is no ACTH suppression with CRH/desmopressin, then adrenal imaging is indicated.⁵⁹

Liver
MRI of the Liver
The liver is a common site of metastatic spread. Patients with a history of known or suspected malignancy, especially tumors from the colon, lung, pancreas, and stomach, are at risk for developing hepatocellular carcinoma. Patients with chronic liver disease are also at risk for developing liver cancer and undergo periodic liver screening for focal liver lesion detection, usually with ultrasonography (US). Liver-specific contrast agents (gadobenate dimeglumine (Gd-BOPTA, MultiHance) and gadoxetate disodium (Eovist) are taken up by functionally intact hepatocytes, allowing increased visualization of both tumors and liver metastases. As metastatic liver lesions do not take up these contrast agents, a dedicated liver MRI can help identify tumors as it allows more contrast differentiation between the tumor and normal liver tissue. In patients undergoing PET scans for active malignancies and there are either known liver metastases in need of restaging or indeterminate liver lesions on other imaging (such as PET or CT), a dedicated liver MRI is considered complimentary NOT overlapping and can be approved in addition to PET if the patient otherwise meets criteria for PET approval (see PET Guideline for further guidance).
 

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. 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.^4,7

Kidney
PRO-PKD Score^22,60
The PRO-PDK score is to assess prognosis in ADPKD, risk scoring system is on the basis of PKD mutation and clinical parameters.

Fever of Unknown Origin
Initial work up prior to CT/MRI would include a comprehensive history, repeated physical exam, complete blood count with differential, three sets of blood cultures, chest X-ray, complete metabolic panel, urinalysis, ESR, ANA, RA, CMV IgM antibodies, virus detection in blood, heterophile antibody test, tuberculin test, and HIV antibody test.⁶¹ Lastly, with a negative CXR, only when initial workup and abdomen/pelvis CT/MR fail to identify the cause for fever can Chest CT be approved. If CXR suggests a malignancy and/or source of fever, then Chest CT would be approved.

Paraneoplastic Syndromes
Suspected paraneoplastic syndromes with no established cancer diagnosis: laboratory evaluation and imaging

The laboratory evaluation for paraneoplastic syndrome is complex. If the appropriate lab test results are suspicious for malignancy, imaging is indicated.

For SIADH (hyponatremia + increased urine osmolality), there is a high association with small cell lung cancer, therefore imaging typically starts with chest CT. If other symptoms suggest a different diagnosis other than small cell lung cancer, different imaging studies may be reasonable.

For hypercalcemia (high serum calcium, low-normal PTH, high PTHrP) it is reasonable to start with bone imaging followed by a more directed evaluation such as mammogram, chest, abdomen, and pelvis imaging as appropriate.

For Cushing syndrome (hypokalemia, normal-high midnight serum ACTH not suppressed with dexamethasone) abdominal and chest imaging is reasonable. If dexamethasone suppression test does suppress ACTH, pituitary MRI is reasonable.

For hypoglycemia, labs drawn during a period of hypoglycemia (glucose < 55, typically a 72 hour fast) (insulin level, C-peptide, and IGF-2:IGF-1 ratio) should be done to evaluate for an insulinoma. An elevated insulin level, elevated C-peptide and/or normal IGF-2:IGF-1 ratio warrants CT or MRI abdomen to look for insulinoma. A low insulin, low C-peptide and/or elevated IGF-2:IGF-1 ratio warrants chest and abdominal imaging.

When a paraneoplastic neurologic syndrome is suspected, nuclear and cytoplasmic antibody panels are often ordered to further identify specific tumor types. Results are needed prior to imaging. Because these tests are highly specific, if an antibody highly associated with a specific cancer is positive, then further imaging for that cancer is reasonable. For example, anti-Hu has a high association with SCLC and chest CT would be reasonable. Anti-MA2 has a high association with testicular cancer and testicular ultrasound would be a reasonable next step.

Weight Loss
Unintentional weight loss is considered clinically significant if the amount of weight lost over 12 months is ≥ 5%. Older age and higher percentage of weight loss correlates with higher likelihood of malignancy. A targeted evaluation is recommended when there are signs or symptoms suggestive of a specific source. For example, when there is clinically significant weight loss with abdominal pain that prompts an evaluation for an abdominal source of the weight loss; CXR and labs such as TSH would not be needed prior to abdominal imaging. Conversely a smoker with a cough and weight loss would not start with abdominal imaging, a chest X-ray (CXR) would be the first test to start with. When there is no suspected diagnosis, initial evaluation includes CXR, age-appropriate cancer screening (such as colonoscopy and mammography) and labs (including CBC, CMP, HbA1C, TSH, stool hemoccult, ESR/CRP, HIV, Hepatitis C). If this initial evaluation fails to identify a cause of weight loss, then the patient is monitored and if progressive weight loss is seen on subsequent visits/weights, then CT Abdomen/Pelvis is reasonable (MRI if there is a contraindication to CT such as contrast allergy or impaired renal function). Lastly, with a negative CXR, only when initial workup and abdomen/pelvis CT/MR fail to identify the cause for weight loss can Chest CT be approved. If CXR suggests a malignancy and/or source of weight loss, then Chest CT would be approved.

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.

References 

48. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Melanoma: Uveal Version 1.2023. National Comprehensive Cancer Network®. 2023;
49. Scheirey C D, Fowler K J, Therrien J A, Kim D H, Al-Refaie W B et al. ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. Journal of the American College of Radiology. 2018; 15: S217 - S231. 10.1016/j.jacr.2018.09.010.
50. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Kidney Cancer V3.2024. National Comprehensive Cancer Network®. 2024; 1,23.
51. Shuman C, Kalish J, Weksberg R. Beckwith-Wiedemann Syndrome. 2000 Mar 3 [Updated 2023 Sep 21]. GeneReviews® [Internet]. 2023;
52. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Colorectal Cancer Screening Version 1.2024. National Comprehensive Cancer Network®. 2024;
53. Hughes D, Pastores G. Gaucher Disease. 2000 Jul 27 [Updated 2023 Dec 7]. GeneReviews® [Internet]. 2023;
54. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Neuroendocrine and Adrenal Tumors V1.2023. National Comprehensive Cancer Network®. 2023; Version 1.2023: 70-71.
55. 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.
56. Else T, Greenberg S, Fishbein L. Hereditary Paraganglioma-Pheochromocytoma Syndromes. 2008 May 21 [Updated 2023 Sep 21]. GeneReviews® [Internet]. 2023;
57. van Leeuwaarde R, Ahmad S, van Nesselrooij B, et al. Von Hippel-Lindau Syndrome. 2000 May 17 [Updated 2024 Feb 29]. GeneReviews® [Internet]. 2024;
58. ARUP Consult. Adrenal Hyperfunction (Cushing Syndrome) Testing Algorithm. ARUP. 2024; Accessed: May 2024. https://arupconsult.com/algorithm/adrenal-hyperfunction-cushing-syndrome- testing-algorithm.
59. Nieman L K, Biller B M K, Findling J W, Newell-Price J, Savage M O et al. The diagnosis of Cushings syndrome: an Endocrine Society Clinical Practice Guideline. The Journal of clinical endocrinology and metabolism. 2008; 93: 1526-40. 10.1210/jc.2008-0125.
60. 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: 10.1681/ASN.2015010016.
61. Katabathina V S, Dasyam A K, Dasyam N, Hosseinzadeh K. Adult bile duct strictures: role of MR imaging and MR cholangiopancreatography in characterization. Radiographics : a review publication of the Radiological Society of North. 2014; 34: 565-86. 10.1148/rg.343125211.

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 non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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