What documentation does Anthem require for CPT 74177?

Ordering physician clinical notes; Prior imaging reports; Relevant laboratory results

How much does Medicare pay for CPT 74177 in 2026?

In 2026, the national Medicare allowable for CPT 74177 is $300.27 in an office setting and $300.27 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 74177?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Anthem Prior Authorization for CPT 74177

CT, MRI, and MR angiography of abdomen and/or pelvis with various contrast protocols including CT angiography combinations · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Anthem clinical policy

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Anthem requires prior authorization for CT abdomen/pelvis with contrast via AIM Specialty Health. Criteria include acute abdominal symptoms with clinical concern, cancer staging or surveillance, suspected abscess, perforation, or vascular pathology. Documentation must include clinical indication and any prior workup.

Documentation checklist

✓Ordering physician clinical notes
✓Prior imaging reports
✓Relevant laboratory results

Submission channels

Phone

1-800-274-7767

2026 Medicare rate for CPT 74177

Office (non-facility)

$300.27

Facility

$300.27

Total RVUs (office)

8.99

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 74177 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Ordering physician clinical notes, Prior imaging reports, Relevant laboratory results.
3Submit via phone, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Anthem require prior authorization for CPT 74177?: Yes. Anthem requires prior authorization for CPT 74177 (CT, MRI, and MR angiography of abdomen and/or pelvis with various contrast protocols including CT angiography combinations) under Standard commercial plans per its published clinical policy.
What documentation does Anthem require for CPT 74177?: Ordering physician clinical notes; Prior imaging reports; Relevant laboratory results
How much does Medicare pay for CPT 74177 in 2026?: In 2026, the national Medicare allowable for CPT 74177 is $300.27 in an office setting and $300.27 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 74177?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Anthem PA lookups

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CPT 74177 prior authorization by payer

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