Description
*Abdominal Magnetic Resonance Imaging (MRI) is a proven and useful tool for the diagnosis, evaluation, assessment of severity, and follow-up of diseases of the abdomen and avoids exposing the patient to ionizing radiation. MRI may be the best imaging procedure for patients with allergy to radiographic contrast material or renal failure. It may also be the procedure of choice for suspected lesions that require a technique to detect subtle soft-tissue contrast and provide a three dimensional depiction of a lesion. Abdominal MRI studies are usually targeted for further evaluation of indeterminate or questionable findings, identified on more standard imaging exams such as ultrasound (US) and CT.

Magnetic Resonance Enterography is an excellent study for assessing submucosal pathology in inflammatory bowel disease. It generates highly reproducible images of the large and small bowel with excellent sensitivity and specificity. It can determine the presence and extent of transmural inflammation, fibrotic disease, and other intra-abdominal complications. It is also useful in assessment of bowel obstruction, abscess formation, tethering and fistula and is less dependent on bowel distention than CT enterography (Arif-Tiwari, 2019).

In diagnosing acute pancreatitis, MRI and MRCP are not as practical as CT. The latter can be performed more quickly and provide better images due to less motion artifact (if patient cannot cooperate with instructions for MRI) in acutely ill patients (ACR, 2019). In selected patients, however, such as those who cannot receive iodinated contrast for CT, MRI/MRCP may be considered or used in a complementary fashion to CT. Complications of chronic pancreatitis using MRCP are well-imaged in cooperative patients.

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 (Bruix, 2011). The literature differs on the role of AFP (alpha fetoprotein) in the screening of HCC. Some authors argue against its use altogether due to its lack of sensitivity and specificity in detecting HCC (Bruix, 2011; Marquardt, 2016) and instead recommend ultrasound alone for screening. According to Marquardt, the AASLD and EASLD (European Association for the Study of the Liver) “do not endorse its [AFP] use in clinical routine, neither alone nor in combination with ultrasound." This approach is supported by reports of patients with chronic viral hepatitis and elevated AFP but normal livers on imaging. AFP elevation in these cases is due to hepatic inflammation and viral replication (Patil, 2013), not neoplasm. Others advocate for combined ultrasound and AFP for screening (Tan, 2011; Tzartzeva, 2018) citing increased sensitivity compared to ultrasound alone in detecting early-stage HCC particularly in cirrhotic patients. In a meta-analysis by Tzartzeva, et al. of thirty-two studies (13,367 patients with cirrhosis) ultrasound with AFP had a 63% sensitivity of detecting early-stage HCC compared to 45% for ultrasound alone. In the final analysis, no literature supports the use of AFP alone in the screening of HCC.

MRI or MRCP for surveillance of cholangiocarcinoma in patients with PSC, other risk factors: Cholangiocarcinoma, a cancer with an increase in incidence globally, is very aggressive with 95% of patients dying within 5 years. Because of the superior sensitivity of MRI compared with ultrasound to detect cholangiocarcinoma, it is preferred for imaging surveillance. In a large study of PSC patients, regular surveillance was associated with a higher 5-year survival (Bowlus, 2019).

If there are signs or symptoms of pheochromocytoma, plasma-free metanephrine and normetanephrine levels or urinary fractionated metanephrines should be obtained prior to biopsy. Imaging is recommended with CT (MRI as second option) once biochemical evidence confirmed.

Otherwise, endocrine workup of an incidental adrenal mass is controversial. Current guidelines from the American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons recommend an initial biochemical evaluation of all adrenal incidentalomas to exclude pheochromocytoma, subclinical Cushing’s syndrome, and hyperaldosteronism.

MRI and insulinoma — Insulinomas are rare pancreatic tumors. Localization of the tumor by ultrasound or CT are the preferred initial options once a diagnosis has been made, followed by endoscopic ultrasound or arterial stimulation with hepatic venous sampling. Whipples triad includes symptoms of hypoglycemia, low blood glucose relieved by ingestion of glucose, and benign 90%. Work-up prior to imaging should include a 72-hour fast with serial glucose and insulin levels over this period until the patient becomes symptomatic. An insulin/glucose ratio of greater than 0.3 has been found in virtually all patients with insulinoma or other islet cell tumors (Vinik, 2017).

MRI for the evaluation of vascular abnormalities such as renal artery stenosis and celiac/superior mesenteric artery stenosis (in chronic mesenteric ischemia) - Doppler Ultrasound, MRA, or CTA should be considered as the preferred imaging modalities.

Imaging of hernias: Most hernias are diagnosed clinically with imaging recommended for the diagnosis of occult hernias or in the evaluation of hernia complications, such as bowel obstruction or strangulation. To detect occult hernias, ultrasound is a first-line study with a sensitivity of 86% and specificity of 77%, compared to 80% sensitivity and 65% specificity for CT (Robinson, 2013). According to Miller, et al. “Magnetic resonance imaging is generally not considered a first- or even second-line evaluation modality for hernias…” (Miller, 2014). Based on this analysis, MRI is recommended only when ultrasound and CT have been performed and fail to make a diagnosis.

Ultrasound: Ultrasound is the initial imaging technique used for screening suspected biliary or pancreatic disease, but it has limited ability to characterize abnormalities in the biliary and pancreatic ducts.

Endoscopic retrograde cholangiopancreatography (ERCP): ERCP can combine diagnosis with therapeutic intervention, e.g., removal of stones, but it is an invasive procedure that carries significant risk of complications, e.g., pancreatitis. ERCP is also technically challenging in patients with post- surgical biliary and/or surgical anastomoses.

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, MRE (Enterography), and MRU (Urography). Multiple authorizations are not typically required. When both 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 is 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

Evaluation of suspicious known mass/tumors for further evaluation of indeterminate or questionable findings

• Initial evaluation of suspicious abdomen masses/tumors found only in the abdomen by physical exam or imaging study, such as ultrasound (US), or CT.¹
• Surveillance: One follow-up exam to ensure no suspicious change has occurred in a tumor in the pelvis. No further surveillance MR unless tumor(s) is/are specified as highly suspicious or change was found on exam or last follow-up imaging.

Initial staging of known cancer

Follow-up of known cancer^2,3:

• In patient undergoing active treatment within the past year or per surveillance imaging tip sheet that summarizes NCCN recommendations³
• With suspected pelvic metastasis based on a sign, symptom, (e.g., anorexia, early satiety, intestinal obstruction, night sweats, pelvic pain, weight loss, vaginal bleeding) or an abnormal lab value (alpha-fetoprotein, CEA, CA 19-9, p53 mutation)
• For abnormal incidental abdominal lymph nodes when follow-up is recommended based on prior imaging (initial 3-month follow-up)⁴
• For known prostate cancer abdomen MRI can be approved when requested in combination with pelvis MRI when meets GL for pelvis MRI

For evaluation of an organ or abnormality seen on previous imaging

ADRENAL

• To locate a pheochromocytoma once there is clear biochemical evidence (See Background)⁵
• Suspected adrenal secreting tumor after full clinical and biochemical work-up^{6, 7}
• Suspected adrenal mass ≥ 1 cm incidentally discovered with no history of malignancy (one follow- up in 6 – 12 months to document stability)
• If adrenal mass ≥ 4 cm and no diagnosis of cancer, can approve for preoperative planning (surgery to rule out adrenal cortical carcinoma)
• For adrenal mass < 4 cm with history of malignancy (if ≥ 4 cm consider biopsy or FDG-PET/CT unless pheochromocytoma is suspected)
• Yearly surveillance for patients with Multiple Endocrine Neoplasia type 1 (MEN1) beginning at age 10⁸
• For patients with Von Hippel Lindau (VHL) surveillance at least every other year starting at age 16 (abdominal ultrasound starting at age 8)⁹
• Surveillance MRI (include¹⁰ pelvis) every 2 – 3 years for patients with Hereditary Paraganglioma syndromes types 1 – 5¹⁰

LIVER

• Indeterminate liver lesion ≥ 1cm seen on prior imaging¹¹
• Indeterminate liver lesion < 1cm on initial imaging, with known history of extrahepatic malignancy, or known chronic liver disease
• Hepatitis/hepatoma screening after ultrasound is abnormal, equivocal, or non-diagnostic (may be limited in patients who are obese, those with underlying hepatic steatosis, as well as nodular livers).^12-15 (No literature supports the use of AFP alone in the screening of HCC).
• For jaundice or abnormal liver function tests after equivocal or abnormal ultrasound¹⁶
• For surveillance of HCC in patients who have received liver-directed therapy, surgical resection, medical treatment, or transplant (MRI or CT) at one-month post treatment and then every 3 months for up to two years (See Background)^{16, 17}
• For follow-up of suspected adenoma every 6 – 12 months
• For surveillance of patients with primary sclerosing cholangitis (also CA 19-9), every 6 – 12 months after the age of 20 (MRI and MRCP preferred over CT)¹⁸
• For follow up of focal nodular hyperplasia (FNH) annually if US is inconclusive¹⁹
• For elastography in chronic liver disease to stage hepatic fibrosis¹⁵ when transient elastography with ultrasound is insufficient
• In patients with Beckwith-Wiedemann syndrome and abnormal ultrasound or rising AFP²⁰
• In Gaucher Disease when ultrasound (including Doppler assessment of portal blood flow) is insufficient²¹
  • For initial evaluation
  • To evaluate gross scarring and/or portal hypertension
  • To monitor hepatic volume/hepatomegaly annually

Evaluation of iron overload in the following settings

• Initial evaluation of liver iron in Hemochromatosis diagnosed in lieu of liver biopsy²²
• Annual evaluation for high-risk patients: transfusion-dependent thalassemia major, sickle cell disease, Gaucher Disease, and other congenital anemias²³ when ultrasound is insufficient

PANCREAS

• Pancreatic cystic lesion found on initial imaging
• For follow-up of known intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN) (if there are no high-risk characteristics, see Background section)²⁴:
  • For incidental and asymptomatic cysts < 5 mm, one follow-up at three years²⁵
  • For cysts 5mm-1cm image every 2 years for 4 years, and if stable may lengthen intervals
  • For cysts 1 – 2cm image every year for 3 years and if stable every 2 years for 4 years, and if stable may lengthen intervals
  • Cysts that are 2 – 3 cm followed every 6 – 12 months for 3 years and if stable then yearly for 4 years and if stable may lengthen intervals (can also use EUS-Endoscopic ultrasound)
  • For lesions ≥ 30 mm MRI/CT or EUS every 6 months for 3 years, then imaging alternating
  • with EUS every year for 4 years and consider lengthening interval if stable
• Annual surveillance for individuals determined to have an increased lifetime risk of developing pancreatic cancer, based on genetic predisposition or family history
  • Starting at age 50 or 10 years younger than the earliest age of cancer affected first-degree relative (except with Peutz-Jeghers start at age 30 – 35)
  • Von Hippel Lindau starting at age 16 at least every other year (abdominal ultrasound starting at age 8)
  • Hereditary Pancreatitis starting at age 40 or 20 years before first attack^{3, 26, 27 **}
  • For other approvable genetic syndromes that increase lifetime risks, see Background section
• Annual surveillance for patients with MEN1 for primary neuroectodermal tumors (pNET) starting at age 10 (EUS also considered)
• For localization of an insulinoma, once diagnosis is confirmed (CT preferred)²⁸

RENAL

• For an indeterminate renal mass on other imaging²⁹
• Active surveillance for indeterminate cystic renal mass, not a simple renal cyst³⁰ (See Bosniak criteria in Background section).
• Follow-up for solid renal masses under 1 cm at 6 and 12 months, then annually³¹
• Annual surveillance for patient with tuberous sclerosis and known angiomyolipomas³²
• For surveillance of patients with Von Hippel Lindau at least every other year to assess for clear cell renal cell carcinoma to begin at age 16 (screening with ultrasound starting at around age 8)⁹
• Active surveillance for renal cell carcinoma in patients with Birt-Hogg syndrome every 36 months³³
• 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
• Polycysytic Kidney Disease
  • Total kidney volume (TKV) is an important measure for assessing disease progression as it can determine prognosis through its ability to predict decline in renal function
    • Abdomen MRI is approvable prior to treatment (an ultrasound is not required prior to MR)
    • If MR is contraindicated or cannot be performed, Abdomen CT is approvable

SPLEEN

• Incidental findings of the spleen on ultrasound or CT that are indeterminate³⁴
• In Gaucher Disease when ultrasound is insufficient²¹
  • For initial evaluation
  • To evaluate splenic fibrosis or the presence of focal splenic lesions
  • To monitor splenic volume/splenomegaly annually

Suspected Hernia

• Occult, spigelian, incisional or epigastric hernia when physical exam and prior imaging (ultrasound AND CT) is non-diagnostic or equivoca^l35-38 and limited to the abdomen
• Suspected incarceration or strangulation based on physical exam (guarding, rebound) or prior imaging (CT preferred)³⁹

For evaluation of suspected infection or for follow-up known infection (may approve in conjunction with Pelvis MRI when indicated)

• Persistent abdominal pain not explained by previous imaging/procedure
• Any known infection that is clinically suspected to have created an abscess in the abdomen
• 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
• Suspected peritonitis (would typically need to include MRI Pelvis) 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 with severe abdominal pain or severe tenderness or mass, not responding to antibiotic treatment (prior imaging study is not required for diverticulitis diagnosis)⁴⁰

For evaluation of suspected inflammatory bowel disease or follow-up known disease (includes MR enterography and can also approve Pelvis MRI/MRE)

• For suspected inflammatory bowel disease (Crohn’s disease or ulcerative colitis) with abdominal
• pain AND one of the following^{17, 41, 42:}
  • Chronic diarrhea
  • Bloody diarrhea
• High clinical suspicion after complete work up including physical exam, labs, endoscopy with biopsy^{17, 41-43}
• Known inflammatory bowel disease (Crohn’s or ulcerative colitis) with recurrence or worsening signs/symptoms requiring re-evaluation or for monitoring therapy⁴²

Other indications for abdominal MRI (and pelvis where appropriate) when CT is inconclusive or cannot be completed

• Persistent abdominal/pelvic pain not explained by previous imaging
• To locate a pheochromocytoma once there is clear biochemical evidence (See Background)
• For 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
• Unexplained weight loss of 10% of body weight in two months (patient history is acceptable); with second MD visit documenting further decline in weight⁴⁴
• Unexplained weight loss of 5% of body weight in six months confirmed by documentation to include the following^{45, 46:}
  • Related history and abdominal exam
  • CXR
  • Abdominal ultrasound
  • Lab tests, including TSH
  • Colonoscopy if 50 – 85 years old
• For fever of unknown origin (temperature of ≥ 101 degrees for a minimum of 3 weeks) after
• standard diagnostic tests are negative⁴⁷
• For suspected or known retroperitoneal fibrosis after complete workup and ultrasound to determine extent of disease⁴⁸
• To screen patients with dermatomyositis for occult malignancy⁴⁹
• For diffuse, unexplained lower extremity edema with negative or inconclusive ultrasound⁵⁰
• For suspected May-Thurner syndrome (CTV/MRV preferred)^{51, 52}
• For further evaluation of an isolated right varicocele with additional signs and symptoms that suggest malignancy or suspicious prior imaging findings⁵³

Indication for combination studies for the initial pre-therapy staging of cancer, OR active monitoring for recurrence as clinically indicated OR evaluation of suspected metastases

• ≤ 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine or Lumbar Spine

INDICATIONS FOR MRCP^54-56

• To confirm choledocholithiasis in patients in the acute setting after ultrasound has been completed^56-58
• Suspected acute pancreatitis with atypical signs and symptoms, including equivocal amylase and lipase and diagnosis other than pancreatitis may be possible. (MRCP and CT may be ordered simultaneously in this setting and may be approved)^{56, 59}
• Pancreatitis by history (greater than 4 weeks), (including pancreatic pseudocyst) with continued abdominal pain suspicious for worsening, or re-exacerbation. (MRCP and CT may be ordered simultaneously in this setting and may be approved)^{56, 59}
• Evaluation of suspected congenital anomaly of the pancreaticobiliary tract, e.g., aberrant ducts, pancreas divisum or related complications60
• For confirmation of choledochal cyst after ultrasound has been done⁶¹
• For long-term postoperative surveillance for patients with history of choledochal cyst
• For post-surgical biliary anatomy and complications when ERCP is not possible or contraindicated
• For the 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

INDICATIONS RELEVANT TO ABDOMEN MRI OR MRCP

Pre-operative evaluation

• For abdominal surgery or procedure

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

If both Abdomen and Pelvis MRI are indicated and the Pelvis MRI has already been approved, then the Abdomen MRI may be approved.
 

References 

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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, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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