Pediatric Pelvis Imaging Guidelines

This policy covers pediatric pelvis imaging (ultrasound, CT, MRI, and nuclear medicine/PET procedures and associated CPT codes) for pediatric pelvic signs and symptoms and conditions including female indications (e.g., abnormal uterine bleeding, PID, amenorrhea, endometriosis, adnexal mass, pelvic pain, PCOS, fetal MRI) and male indications (e.g., undescended testis, scrotal pathology, penile/soft-tissue masses). Major limitations/requirements: advanced imaging is reserved for patients with documented active clinical signs or symptoms (not routine screening), usually requires a recent (≤60 days) face‑to‑face evaluation and physician review for atypical presentations, transvaginal ultrasound is restricted to sexually active/tampon‑using consenting patients, repeat imaging is limited to cases with progression or management‑impact, and certain modalities (pelvis MRI with contrast, PET codes) are rarely used.

"PEDPV-12: Scrotal Pathology"