Who reviews prior authorization requests for Ultrasound scan behind the abdominal cavity with limited focus (CPT 76775)?

Most commercial payers hand imaging reviews to a radiology benefit manager. For the payers tracked here, requests are reviewed using guidelines from eviCore, Carelon, CMS, UnitedHealthcare / eviCore. The request is submitted through that organization's portal rather than the health plan's general line.

What should be in the clinical notes before requesting Ultrasound scan behind the abdominal cavity with limited focus (CPT 76775)?

Reviewers look for a recent office visit that documents the symptoms and how long they have lasted, exam findings, results of any earlier imaging, treatments already tried and how the patient responded, and the specific question the study is expected to answer. The diagnosis code on the request should match what the notes describe.

CPT 76775: Ultrasound scan behind the abdominal cavity with limited focus - Prior Authorization and Price

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CPT 76775

Ultrasound scan behind the abdominal cavity with limited focus.

Ultrasound

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Abdomen Imaging Guidelines 1.0.2026, effective Feb 3, 2026 Pediatric Abdomen Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Peripheral Vascular Disease (PVD) Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026	25 that name this code
Anthem BCBS	Carelon	Current guideline	None found
Cigna	eviCore	Abdomen Imaging Guidelines 1.0.2026, effective Feb 3, 2026 Pediatric Abdomen Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Peripheral Vascular Disease (PVD) Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026	25 that name this code
Medicare	CMS	—	None found
Original Medicare does not run a prior authorization program for outpatient imaging; claims are judged against the coverage policies above. Medicare Advantage plans set their own prior authorization rules.
UnitedHealthcare	UnitedHealthcare / eviCore	Commercial and Exchange Cardiovascular and Radiology Imaging Guidelines 09.2026, effective Sep 1, 2026	25 that name this code

Guidelines collected from the payers' published documents on September 29, 2026. Payers revise these documents during the year. Open the guideline link to confirm the current version before you submit.

Conditions the guidelines address for this study

These are the clinical situations where payer guidelines discuss Ultrasound scan behind the abdominal cavity with limited focus. Each has its own criteria for when the study is considered appropriate.

Flank Pain, Rule Out or Known Renal/Ureteral Stone Aetna · Cigna · UnitedHealthcare
Urinary Tract Infection (UTI) Aetna · Cigna · UnitedHealthcare
Polycystic Kidney Disease Aetna · Cigna · UnitedHealthcare
Renal Failure Aetna · Cigna · UnitedHealthcare
Retroperitoneal Fibrosis Aetna · Cigna · UnitedHealthcare
Transplant Aetna · Cigna · UnitedHealthcare
Flank Pain, Renal Stone Aetna · Cigna · UnitedHealthcare
Hematuria Aetna · Cigna · UnitedHealthcare
Congenital (Mullerian) Uterine and Vaginal Anomalies Aetna · Cigna · UnitedHealthcare
Kyphosis and Scoliosis Aetna · Cigna · UnitedHealthcare
Medical Conditions with Cancer in the Differential Diagnosis Aetna · Cigna · UnitedHealthcare
Screening for Peripheral Artery /Aneurysmal Disease Aetna · Cigna · UnitedHealthcare
Transitional Cell Cancer Aetna · Cigna · UnitedHealthcare
Urinary Incontinence/Pelvic Prolapse/Fecal Incontinence Aetna · Cigna · UnitedHealthcare

Typical price

Commercial insurance, median

$269

Middle half of rates: $146 to $507

Medicare, hospital outpatient

$107

Facility payment

Medicare, physician fee schedule

$61

National, non-facility

Commercial figures come from negotiated rates published by 1,037 hospitals; Medicare figures from CMS fee schedules. Rates vary widely by hospital and plan. Pricing data from CenterIQ.

Get notified when the rules for this study change

Payers update imaging guidelines several times a year. We will email you when the criteria for Ultrasound scan behind the abdominal cavity with limited focus change.

CPT 76775: Ultrasound scan behind the abdominal cavity with limited focus - Prior Authorization and Price

Payer guidelines that apply

Conditions the guidelines address for this study

Typical price

Get notified when the rules for this study change

Frequently asked questions

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