Pelvis Imaging Guidelines

This policy covers appropriate use of pelvic imaging (pelvic and transvaginal ultrasound, pelvic MRI and CT) for a broad range of female and male pelvic conditions—examples include abnormal uterine bleeding, amenorrhea, adnexal/ovarian masses, endometriosis, PID, PCOS, infertility, IUD/tubal occlusion issues, pelvic pain, fibroids, selected male pelvic disorders, and pregnancy/fetal imaging. Major limitations require a current clinical evaluation with relevant history/physical and prior non‑advanced imaging (eg, pelvic/transvaginal ultrasound) before advanced imaging, restrict routine use of ionizing radiation in pregnancy (favor MRI without contrast and limit CT to select circumstances), do not support transvaginal/pelvic ultrasound or gynecology CPT codes for known pregnancy, and mandate physician review for atypical presentations.

"This tool addresses common symptoms and symptom complexes."