Pediatric Pelvis Imaging Guidelines

This policy covers diagnostic pelvic imaging in pediatric patients — including ultrasound, CT, MRI, selective nuclear medicine and fetal MRI — for evaluation of common pelvic symptoms and specific conditions such as abnormal uterine bleeding, PID, amenorrhea, endometriosis, suspected adnexal mass, pelvic pain/ovarian torsion, PCOS, undescended testis, scrotal and penile pathology, incontinence and patent urachus. Advanced imaging requires a documented pertinent clinical evaluation (history, physical, labs and basic imaging such as plain radiography or ultrasound, or a meaningful telehealth/telephone/electronic contact), must document active pelvic signs/symptoms (no asymptomatic screening), atypical or out‑of‑tool presentations need physician review, and certain studies (e.g., transvaginal ultrasound) and PET/contrast MRI codes are limited or rarely used in pediatrics.

"Patent Urachus"