Pediatric Pelvis Imaging Guidelines

This policy covers pediatric pelvic imaging—primarily ultrasound and MRI (MRI pelvis without contrast 72195; MRI with contrast 72196 rarely used), with CT and limited nuclear/PET in specific cases—to evaluate pediatric pelvic conditions such as abnormal uterine bleeding, PID, amenorrhea, endometriosis, suspected adnexal mass, pelvic pain/ovarian torsion, PCOS, scrotal pathology, undescended testis, fetal MRI, and related presentations. Advanced imaging is limited to individuals ≤18 with documented active clinical signs/symptoms and requires prior pertinent clinical evaluation (history, physical exam, appropriate labs and initial imaging such as ultrasound); transvaginal ultrasound is restricted to sexually active or tampon-using adolescents (transabdominal ultrasound preferred otherwise), asymptomatic screening is not supported, repeat studies generally require evidence of progression or impact on management, and atypical presentations need physician review.