Pediatric Pelvis Imaging Guidelines

This policy covers pediatric pelvic imaging, including guideline-directed use of ultrasound and MRI pelvis (CPT 72195; CPT 72196 noted as rarely used), for evaluation of pediatric pelvic conditions such as abnormal uterine bleeding, PID, amenorrhea, endometriosis, suspected adnexal mass, pelvic pain/ovarian torsion, PCOS, scrotal pathology, undescended testis, fetal pelvic concerns and other common symptom complexes. Major limitations: it applies to pediatric patients only and supports advanced imaging only for documented active signs or symptoms after appropriate clinical evaluation and basic imaging/laboratory workup (ultrasound preferred initially); atypical presentations require physician review, repeat studies need evidence of progression or management impact, and certain modalities/codes are restricted or rarely used.

"Amenorrhea (PEDPV-4)"

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