Pediatric Pelvis Imaging Guidelines

This policy covers pediatric pelvis imaging—primarily ultrasound and MRI (CPT 72195–72197 and related codes)—for a broad range of pediatric pelvic conditions including general pelvic assessment, abnormal uterine bleeding, PID, amenorrhea, endometriosis, suspected adnexal mass, pelvic pain/ovarian torsion, PCOS, fetal pelvic MRI, undescended testis, and scrotal/penile pathologies. Advanced imaging is limited to patients with documented active clinical signs/symptoms after appropriate history, exam, labs and usually initial ultrasound; routine screening of asymptomatic patients, MRI with contrast or unlisted/PET procedures in pediatrics, transvaginal ultrasound for non–sexually active patients, and repeat imaging without evidence of progression generally are not supported and may require physician review.

"Undescended testis (PEDPV-11)"

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