Pelvis Imaging Guidelines

This policy covers pelvis imaging (pelvic/transvaginal ultrasound, MRI, CT and related imaging procedures) for evaluation of common pelvic symptoms and conditions including abnormal uterine bleeding, pelvic pain/dyspareunia, adnexal masses/ovarian cysts, endometriosis, PID, PCOS, infertility, IUD/tubal issues, leiomyomata, fetal/obstetric concerns and select male pelvic/penile conditions. Major limitations require prior non‑advanced imaging (eg, pelvic/transvaginal ultrasound) and a clinical evaluation within 60 days with relevant history, exam, labs and prior studies before advanced imaging is considered; pregnant patients should be evaluated with ultrasound or non‑contrast MRI (CT and contrast generally avoided), atypical presentations need physician review, and specific CPT/3D rendering codes have defined reporting criteria.

"If the uterus rises out of the pelvic cavity, the imaging field can be determined on scout films."