CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting

This policy addresses non‑obstetric, gynecologic duplex ultrasonography of the abdomen and pelvis in the outpatient setting (CPT 93975, 93976). It is medically necessary when a documented history and physical indicate the need to visualize vascular characteristics—e.g., evaluation or suspicion of abnormal uterine bleeding, endometrial polyps, endometriomas, or neoplasm. It is not medically necessary when these criteria are not met, including for routine screening of asymptomatic individuals or for repeat studies without a change (or suspected change) in prior exam findings; the policy applies to any person with female reproductive/genitourinary systems regardless of gender identity.

"Non-obstetric, gynecologic, duplex ultrasonography of the abdomen or pelvis, in the outpatient setting, is consideredmedically necessarywhen there is a documented health history and physical examin..."