Pelvis Imaging Guidelines

This policy covers pelvis imaging—including transvaginal and pelvic ultrasound, pelvic MRI, CT when appropriate, and selective 3‑D rendering—for patients with common pelvic symptoms and conditions such as abnormal uterine bleeding, amenorrhea, adnexal masses/ovarian cysts, endometriosis, pelvic inflammatory disease, infertility/IUD issues, fibroids, pelvic pain, fetal indications, and related disorders. Major limitations/requirements include a current clinical evaluation within 60 days or physician review for atypical presentations, preferential use of ultrasound or non‑contrast MRI in pregnancy (CT only in selected, justified circumstances with radiation protection), restrictions on substituting pelvic for transvaginal ultrasound (pelvic US is complementary or reserved for pediatric/non‑sexually active patients), and specific MD‑review and reimbursement rules for 3‑D rendering and certain CPT codes.

"This tool addresses common symptoms and symptom complexes."