Pelvis Imaging Guidelines

This policy covers pelvis imaging—primarily ultrasound, CT, and MRI (including fetal MRI)—for individuals presenting with common pelvic signs/symptoms and typical clinical presentations addressed by the eviCore tool, particularly female conditions such as abnormal uterine bleeding, amenorrhea, adnexal/ovarian cysts, endometriosis, PID, infertility, IUD issues, pelvic pain/dyspareunia, leiomyomata, uterine anomalies, and pregnancy‑related indications. Major limitations/requirements include a documented clinical evaluation within 60 days (history, physical, and/or labs/non‑advanced imaging) before advanced imaging, physician review for atypical or unaddressed presentations, preference for transvaginal ultrasound with transabdominal substitution only for pediatric or non‑sexually active patients, pregnant patients limited to ultrasound or MRI without contrast, and restricted CT use due to limited soft‑tissue resolution and contrast allergy considerations.

"Abdominal imaging begins at the diaphragm and extends to the umbilicus or iliac crest."