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CT scan prior authorization for abdominal pain

Updated: Jul 21, 2023

Is Preauth Required? CT scans of the abdomen and pelvis can be used for diagnosis and treatment of abdominal pain. Preauthorization is usually required when the CT scan is being used for diagnosis or for treatment of abdominal pain.

Will the claim be denied? Claims for CT scans for abdominal pain may be approved if they meet the criteria outlined in the evidence, such as recommendations from the American College of Radiology, indications for abdominal and/or pelvic CT examinations, and the published literature that supports the use of CT of the abdomen and pelvis as a first-line modality for the evaluation of abdominal/pelvic pathology. Claims for CT scans for abdominal pain may be denied if they do not meet the criteria outlined in the evidence, such as not being ordered by the treating physician or not being reasonable and necessary.

When is the following treatment medically necessary for the condition specified? A CT scan is considered medically necessary for abdominal pain if the patient is presenting with acute traumatic abdominal injury, aneurysm and other primary vascular abnormalities, occlusive disease, acute GI hemorrhage, congenital anomaly, prior to arterial interventional procedures or open surgical procedures, severe or difficult to control renal hypertension, progressive renal insufficiency, or planning for radiation therapy as well as guidance of interventional, diagnostic, or therapeutic procedures within the abdomen and pelvis, including preparation for TAVI/TAVR. Medical record documentation must clearly indicate the medical necessity of the service being billed.

What would make the following treatment considered medically necessary? CT scans are considered medically necessary for the evaluation of abdominal pain according to the American College of Radiology (ACR) practice parameters published in 2016, as well as the ACR appropriateness criteria for nonlocalized abdominal pain published in 2018. CT scans are often the first-line modality, quickly evaluating the abdomen/pelvis, providing for accurate diagnoses and management of patients with abdominal pain.

What are the relevant codes for the treatment? The CPT code for a CT scan of the abdomen and pelvis without contrast material is 74176. The CPT code for a CT scan of the abdomen and pelvis with contrast material is 74177. The CPT code for a CT scan of the abdomen and pelvis without contrast material followed by contrast material and further sections in one or both body regions is 74178. Modifiers may be used when billing for non-covered services. No ICD-10-CM codes that support medical necessity are listed for this treatment and condition. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.

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