MRI (Magnetic Resonance Imaging), MRE (Magnetic Resonance Enterography), and MRCP (Magnetic Resonance Cholangiopancreatography) of the Abdomen Form

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MRI (Magnetic Resonance Imaging) of the Abdomen Medical Guideline

Service: MRI (Magnetic Resonance Imaging), MRE (Magnetic Resonance Enterography), and MRCP (Magnetic Resonance Cholangiopancreatography) of the Abdomen

PUM 250-0061-1812

Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026

Related Medical Guidelines:

• MRI (Magnetic Resonance Imaging) of the Pelvis Medical Guideline

Description:

MRI of the Abdomen can be used for diagnosis, evaluation, assessment of severity, and follow-up of diseases of the abdomen and avoids exposing the patient to ionizing radiation. MRI Abdomen is also used for further evaluation of indeterminate or questionable findings, identified on standard imaging exams (such as Ultrasound [US] and Computed Tomography [CT]).

For purposes of this guideline, there is no MRI Abdomen/Pelvis as there is CT Abdomen/Pelvis. If imaging of both the abdomen and pelvis are indicated, two separate exams (and authorizations) are required (i.e., MRI Abdomen and MRI Pelvis).

MRE (magnetic resonance enterography) is used to assess the bowel.

MRCP (magnetic resonance cholangiopancreatography) is used to assess the biliary tree and pancreatic ductal system.

When both MRCP and MRI abdomen are requested, it must be clearly documented why both are needed.

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Indications of Coverage:

An Abdominal MRI is considered medically necessary for ANY of the following indications, when at least ONE of the additional criteria noted are met:

A. Initial staging of documented cancer

B. Follow-up of known cancer:

1. Patient undergoing active treatment within the past year or as per NCCN surveillance imaging guidance for that cancer.

2. Suspected abdominal metastasis based on a sign/symptom or an abnormal laboratory tumor marker, or a physical exam finding.

   C. Further evaluation of indeterminate or questionable findings of masses seen on ultrasound or CT:

3. Initial imaging (see organ specific guidance below)
4. One follow-up exam to ensure no suspicious change has occurred in a tumor in the abdomen or pelvis. No further surveillance by MR unless tumor(s) is/are specified as highly suspicious, or change was found on exam or last follow-up imaging.

5. Incidental abdominal or pelvic lymph nodes when follow-up is recommended based on prior imaging (initial 3-month follow-up) and PET scan has not been performed.

   D. Evaluation of an organ or abnormality seen on previous imaging or as noted below:

   Adrenal:
   • Indeterminate adrenal lesion seen on prior imaging. • Evaluation of suspected adrenal tumors and/or endocrine disorders when there is clinical and laboratory evidence to suggest an adrenal source. • Adrenal mass < 4 cm incidentally discovered with benign characteristics, 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 annually x 2 years. • Multiple Endocrine Neoplasia type 1 (MEN1) every 1-3 years (chest CT or MRI also approvable for this syndrome at same interval).

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• Von Hippel Lindau (VHL) with either personal history or family history in 1st degree relative of VHL, every 2 years, beginning at age 16, can also approve pelvis MRI.
• Hereditary Paraganglioma syndromes every 2-3 years IF whole body (WB) MRI not available (WB MRI is the preferred study; If unable to do whole body MRI may approve abdomen MRI, pelvis MRI, skull base and neck MRI and chest CT). SDHB [succinate dehydrogenase complex iron sulfur subunit B] mutation may start at age 6, all other SDHx [succinate dehydrogenase genes] start at age 10.

Liver: • Indeterminate liver lesion seen on prior imaging. • In patients at high risk for hepatocellular carcinoma (HCC) (i.e., known cirrhosis and/or chronic Hepatitis B), with an Alpha fetoprotein level which is abnormally high and progressively rising on consecutive lab evaluations.
• Screening in patients at high risk for HCC every 6 months when prior ultrasound is insufficient to evaluate the liver due to fatty or nodular liver or large body habitus. The ultrasound report should indicate that the visualization of the entire liver is suboptimal, and that MRI is recommended. • Jaundice or abnormal liver function tests after equivocal or abnormal ultrasound or CT. • Surveillance of HCC (MRI or CT) in patients who have received liver-directed therapy, surgical resection, medical treatment, or transplant at one-month post treatment and then every 3 months for up to two years, then every 6 months. • Follow-up of suspected adenoma every 6 months for 2 years, and then annually, to establish any growth patterns and assess for malignant transformation. • Surveillance of patients with primary sclerosing cholangitis [PSC], every 6-12 months after the age of 20 (MRI and MRCP preferred over CT). • 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 question. • For annular elastography in chronic liver disease to stage hepatic fibrosis when transient elastography with ultrasound is insufficient. MRE can be approved for either of the following: If Transient Elastography failure despite use of an XL-probe, OR BMI ≥ 35; OR Conflict between clinical picture and transient elastography results (e.g., patient with portal hypertension but VCTE [vibration- controlled transient elastography] suggests no fibrosis).

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• In patients with Beckwith-Wiedemann syndrome and abnormal ultrasound or rising AFP. • Evaluation of known liver metastases, even if PET has been completed, liver MRI is medically necessary. • Evaluation and monitoring of Gaucher Disease at initial diagnosis and every 12 to 24 months.

Evaluation of iron overload in the following settings: -Hereditary hemochromatosis, known or suspected

-Annual evaluation for high-risk patients: transfusion-dependent

thalassemia major, sickle cell disease, Gaucher disease, and other

congenital anemias when ultrasound is insufficient.

Pancreas: • Pancreatic cyst in an asymptomatic patient detected incidentally on CT scan, MRI, or ultrasound and 1 or more of the following: o Initial evaluation o Intraductal papillary mucinous neoplasm; every 6 months for 2 years, then annually o Serous cystadenoma; every 2 years • Localization of a functional pancreatic tumor (such as islet cell tumor) with high suspicion of tumor based on biochemical studies and other imaging. • Annual surveillance for individuals determined to have an increased lifetime risk of developing pancreatic cancer based on the following:
o SKT11 variant (including Peutz-Jeghers) starting at age 30 (or 10 years younger than the earliest pancreatic cancer diagnosis in the family, whichever is earlier) o CDKN2A variant starting at age 40 (or 10 years younger than the earliest pancreatic cancer diagnosis in the family, whichever is earlier) o Other variants and based on family history 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 a documented mutation in one of the following genes (ATM, BRCA1, BRCA2, MLH1 [Lynch], MSH2, MSH6, EPCAM, PALB2, TP53)  >= 2 first-degree relatives with a history of pancreatic cancer from the same side of the family

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 >= 3 first-and/or second-degree relatives with a history of pancreatic cancer from the same side of the family.
o Hereditary Pancreatitis (such as PRSS1 variant) starting 20 years after onset of pancreatitis, or at age 40 years, whichever is earlier.

Renal:
• Indeterminate renal mass on other imaging.
• Active surveillance for indeterminate cystic renal mass, not a simple renal cyst. For Bosniak type III and type IV lesions, if intervention/resection is not performed, then annual surveillance is medically necessary, provided the results may affect patient management.
• Follow-up for solid renal masses under 3 cm at 6 and 12 months, then annually. • Surveillance for known angiomyolipoma (AML): annually if known tuberous sclerosis (TSC) or AML Size is > 4 cm; every 2 years if AML size is 3-4 cm (if AML <3 cm, CT or MRI not needed unless pt has TSC). • Surveillance of patients with the following known genetic mutations at the following intervals (MRI preferred due to lifetime radiation risk, CT can be approved if needed for surgical planning or CT to MRI):
 BAP1- TPDS (BAP-1 tumor predisposition syndrome) every 2 years starting at age 30.  BHDS (Birt-Hogg-Dube) every 3 years starting at age 20.  HLRCC (hereditary leiomyomatosis and renal cell cancer) annually starting at age 8.  HPRC (hereditary paraganglioma/pheochromocytoma) every 4-6 years starting at age 12.
 TSC (tuberous sclerosis complex) without known AML every 3-5 years starting at age 12.
---TSC + known AML annually. • VHL (Von Hippel Lindau) every 2 years starting at age 16. • MRU (magnetic resonance urography) (may also approve MR pelvis for MR urography) and CT (CTU-computed tomography urography) is contraindicated (such as pregnancy)
• Polycystic kidney disease- o Abdomen MRI is approvable prior to treatment, and for evaluation of indeterminate cystic lesions identified with other imaging.

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Spleen: • Incidental findings of the spleen on ultrasound or CT that are indeterminate.
• Evaluation and monitoring of Gaucher Disease at initial diagnosis and every 12 to 24 months.

Stomach, Small Bowel, Colon: • Indeterminate findings on prior imaging or endoscopy of the stomach, small bowel, or colon; OR
• To determine the full extent of tumor/inflammatory disease affecting these structures.

E. Suspected Hernia:

1. Occult, spigelian, incisional or epigastric hernia when physical exam and prior imaging (CT or Ultrasound) are non-diagnostic or equivocal and limited to the abdomen.

2. Suspected incarceration or strangulation based on physical exam (guarding, rebound) and CT or other imagining is indeterminate or contraindicated.

   F. Evaluation of suspected infection or inflammatory disease when a CT is indeterminate or contraindicated:

3. Persistent abdominal pain not explained by previous imaging/procedure.
4. Laboratory and physical exam findings suspicious for abscess.
5. Abnormal fluid collection limited to the abdomen seen on prior imaging that needs follow-up evaluation. o 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.

6. Suspected complications of diverticulitis unresponsive to antibiotic treatment, and CT is inconclusive or contraindicated.

   G. Evaluation of inflammatory bowel disease (IBD) such as Crohn’s or Ulcerative Colitis (includes MR enterography and can also approve Pelvis MRI/MRE):

7. Suspected inflammatory bowel disease after complete work up including physical exam, labs, and recent colonoscopy.
8. Known inflammatory bowel disease with recurrence or worsening signs/symptoms requiring re-evaluation or for monitoring therapy.

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H. MR Enterography: For evaluation of suspected small bowel bleeding or small bowel tumor or iron deficient anemia ** if ALL of the following are met:

1. Upper endoscopy and colonoscopy have been completed (unless contraindicated) and source of bleeding was not detected.
2. Video capsule endoscopy (unless contraindicated) did not identify the source of bleeding or identified an abnormality requiring additional characterization.

3. CT enterography is either inconclusive or is contraindicated.

   ** For evaluation of iron deficient anemia, extraintestinal sources of bleeding

   must be excluded prior to MRI.

   I. MR Elastography: For evaluation of chronic liver disease with no moderate or severe hepatic iron overload documented (e.g., hemochromatosis, hemosiderosis) and EITHER of the following scenarios:

4. Chronic liver disease excluding nonalcoholic fatty liver disease (e.g., chronic hepatitis C virus infection, chronic hepatitis B virus infection), need to assess for advance fibrosis or cirrhosis AND EITHER patient has BMI of 30 or greater; OR Vibration-controlled transient elastography is unavailable, contraindicated, or results are indeterminate; OR

5. Nonalcoholic fatty liver disease, and hepatic fibrosis or cirrhosis known or suspected.

   J. Abdominal MRI (and pelvis where appropriate):

6. History of fistula in the abdomen that requires re-evaluation or is suspected to have recurred.
7. Prior to liver transplantation (MRCP also approvable) (initial placement on transplant list or part of a transplant evaluation), may repeat studies immediately prior to transplantation with known HCC, PSC, or cholangiocarcinoma (every 3 months while on transplant list).

8. Prior to solid organ transplantation.

   K. Abdominal MRI (and pelvic where appropriate) with persistent abdominal symptoms or high clinical suspicion of abdominal pathology, and prior work up, to include CT is inconclusive or contraindicated.

   L. MRCP (magnetic resonance cholangiopancreatography) is considered medically necessary when at least ONE of the following criteria are met:

9. Confirm choledocholithiasis in patients in the acute setting if ultrasound is non-diagnostic or has findings requiring further evaluation.

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2. Suspected acute pancreatitis with atypical signs and symptoms, including equivocal amylase and lipase and diagnosis other than pancreatitis may be possible. (MRCP and CT/MR may be ordered simultaneously in this setting and may be approved).
3. Pancreatitis by history (greater than 4 weeks), (including pancreatic pseudocyst) with continued abdominal pain suspicious for worsening, or re-exacerbation. (MRCP and CT/MRI may be ordered simultaneously in this setting and may be approved).
4. Evaluation of suspected congenital anomaly of the pancreaticobiliary tract, e.g., aberrant ducts, pancreas divisum or related complications.
5. Confirmation of choledochal cyst after ultrasound has been done.
6. Long-term postoperative surveillance by patients with history of choledochal cyst.
7. Post-surgical biliary anatomy and complications when ERCP [endoscopic retrograde cholangiopancreatography] is not possible or contraindicated.
8. Assessment of benign or malignant biliary strictures.
9. Evaluation of abnormality related to the pancreatic or biliary tree based on symptoms or laboratory findings and initial imaging has been performed or is either contraindicated or is inconclusive or requires further characterization (e.g., renal failure prevents contrast CT or body habitus limits US).
10. Evaluation of pancreatobiliary disease in pregnant patients if ultrasound is non-diagnostic or has findings requiring further evaluation.

11. Evaluation of the bile ducts is required, but anatomy precludes ERCP or ERCP is deemed unsafe, or had been attempted and unsuccessful or inconclusive.

    M. Indications relevant to Abdomen MRI or MRCP:

    • Pre-operative evaluation for abdominal surgery or procedure. • Post-operative/procedural evaluation:
    o Follow-up of known or suspected post-operative complication involving only the abdomen.
    o A follow-up study to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Must include documentation that clearly states why additional imaging is needed.

    N. Requests for repeat MR imaging, after completing MR of the same anatomic site in the past 6 months, will be reviewed on a case-by-case basis. The most recent imaging reports must be submitted, and for the repeat exam to be approved as medically necessary, ONE of the following MUST be met:

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a) documentation that the prior testing was inconclusive, or with short-term follow-up imaging recommended. b) clinical documentation of progressive worsening of symptoms or new physical exam findings prompting the repeat imaging, and that patient management will be altered by the imaging results.
c) interval surgery (with suspected complication) or significant new trauma to that anatomic region.

Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.” A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

D. For colon cancer diagnosis or screening with MR colonography, abdominal MRI is considered experimental, investigational, unproven.

E. The use of MRI for surveillance/follow-up evaluation of renal cysts characterized as Bosniak I or II, is considered not medically necessary.

F. For diagnosis of liver fibrosis and steatosis related to nonalcoholic fatty liver disease and nonalcoholic steatohepatitis, LiverMultiScan (Perspectum) is considered experimental, investigational, and unproven.

G. For diagnosis or management of primary sclerosing cholangitis, MRCP+ (Perspectum) is considered experimental, investigational, and unproven.

Documentation Required:

Prior authorization is required for all abdominal MRI procedures. To obtain prior authorization, the requesting provider must submit the following information:

• A standard written order (SWO), prescribed by a qualified healthcare provider concerning the patient’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. • Correct coding for the service that meets all coding guidelines.

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Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered. State mandates, laws or benchmark supersede this medical guideline.

Imaging is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

**All imaging related to cancer care, WPS uses NCCN as a primary reference.

Guideline Review History:

Implemented 01/01/24, 12/01/24, 09/01/25, 05/01/26 Medical Guideline Committee Approval 11/30/23, 11/21/24, 03/27/25, Q1 2026 Reviewed

11/30/23, 11/21/24, 03/27/25, Q1 2026 Developed 11/30/23

Approved by the Medical Director

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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Codes
Code Description

74181 Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s)
74182 Magnetic resonance (e.g., proton) imaging, abdomen with contrast material(s)
74183 Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences
76391 Magnetic resonance (e.g., vibration) elastography
S8037 Magnetic resonance cholangiopancreatography (MRCP)
0648T Quantitative magnetic resonance for analysis of tissue composition (e.g., fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (e.g., organ, gland, tissue, target structure) during the same session
0649T Quantitative magnetic resonance for analysis of tissue composition (e.g., fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (e.g., organ, gland tissue, target structure) (List separately in addition to code for primary procedure)
0697T Quantitative magnetic resonance for analysis of tissue composition (e.g., fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (e.g., organ, gland, tissue, target structure) during the same session; multiple organs
0698T Quantitative magnetic resonance for analysis of tissue composition (e.g., fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (e.g., organ, gland, tissue, target structure); multiple organs (list separately in addition to code for primary procedure)
0723T Quantitative magnetic resonance cholangiopancreatography (QMRCP) including data preparation and transmission, interpretation and report, obtained without diagnostic magnetic resonance imaging (MRI) examination of the same anatomy (e.g., organ, gland, tissue target structure) during the same session
0724T Quantitative magnetic resonance cholangiopancreatography (QMRCP) including data preparation and transmission, interpretation and report, obtained with diagnostic magnetic resonance imaging (MRI) examination of the same anatomy (e.g., organ, gland, tissue, target structure) (List separately in addition to code for primary procedure)

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ASSOCIATED CODES
A9573 Injection, Gadopiclenol, 1 ml
A9575 Injection, Gadoterate meglumine, 0.1 ml
A9577 Injection, Gadobenate Dimeglumine (Multihance), per ml
A9578 Injection, Gadobenate Dimeglumine (Multihance Multipack), per ml
A9581 Injection, Gadoxetate Disodium, 1 ml
A9585 Injection, Gadobutrol, 0.1 ml
Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml