Pediatric Pelvis Imaging Guidelines

This policy covers pediatric pelvis imaging (e.g., pelvic MRI such as CPT 72195 and pelvic ultrasound) for individuals under 18 for conditions including abnormal uterine bleeding, pelvic inflammatory disease, amenorrhea, endometriosis, suspected adnexal mass/ovarian torsion, pelvic pain/dyspareunia, PCOS, scrotal pathology, undescended testis, fetal pelvic indications, and other pediatric pelvic disorders. Major limitations: ultrasound is the preferred initial test, transvaginal ultrasound is limited to sexually active adolescents or those who consent/use tampons, advanced imaging requires documented active signs/symptoms and prior basic evaluation, routine/repeat imaging without progression or management impact is not supported, and atypical presentations require physician review.

"Unlisted MRI procedure (for radiation planning or surgical software) — CPT 76498"