Pediatric Pelvis Imaging Guidelines

This policy covers pediatric pelvic imaging (ultrasound, CT, MRI, fetal MRI and related studies) for common pediatric pelvic symptoms and conditions such as abnormal uterine bleeding, PID, amenorrhea, endometriosis, suspected adnexal mass, ovarian torsion, PCOS, scrotal pathology, undescended testis and related presentations. Major limitations/requirements: ultrasound is the preferred initial exam and advanced imaging is not supported for asymptomatic screening or without prior clinical evaluation, basic imaging and labs; transvaginal ultrasound is restricted to sexually active/tampon-using adolescents with documented consent; repeat studies require justification and atypical presentations need physician review, while MRI pelvis with contrast and several PET codes are rarely used or not used in pediatrics.

"Ultrasound, pelvic transvaginal — CPT 76830"

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