Pelvis Imaging Guidelines

This policy covers pelvic imaging services (eg, pelvic and transvaginal/transperineal ultrasound, pelvic MRI and related studies) for a wide range of gynecologic, obstetric/fetal and selected male pelvic conditions including abnormal uterine bleeding, amenorrhea, adenomyosis, adnexal masses, endometriosis, PID, PCOS, infertility, IUD/tubal issues, fibroids, fetal MRI, molar pregnancy/GTN, erectile dysfunction and penile soft‑tissue masses. Major limitations/requirements: the tool addresses common/typical presentations (atypical cases require physician review); advanced imaging requires a current clinical evaluation documenting onset/change in symptoms with relevant history/physical, appropriate labs and prior non‑advanced imaging (eg, pelvic or transvaginal ultrasound), and transvaginal/pelvic ultrasound and gynecology CPT codes are not supported in known pregnancy.

"Use of ultrasound in pregnancy (obstetric ultrasonography) as addressed by ACOG Practice Bulletin No."