Pelvis Imaging Guidelines

This policy covers pelvis imaging (ultrasound, MRI, CT and related pelvic imaging) for a wide range of gynecologic, obstetric, urologic and reproductive conditions—examples include abnormal uterine bleeding, adnexal masses/ovarian cysts, endometriosis, PID, leiomyomata/fibroids, infertility/IUD evaluation, pelvic pain/dyspareunia, uterine anomalies, fetal MRI and select male genital conditions. Major limitations/requirements: imaging for atypical presentations requires physician review; advanced imaging is only considered with a documented clinical evaluation within 60 days; in pregnancy avoid ionizing radiation and prefer ultrasound or MRI without contrast (transvaginal ultrasound and gynecology CPT codes are not supported in known pregnancy), and pelvic ultrasound is generally adjunctive to transvaginal imaging with substitution limited to pediatric or non–sexually active females.

"Other meaningful contact (telehealth visit, telephone call, electronic mail or messaging) by an established individual can substitute for a face-to-face clinical evaluation."