CurrentColorado Rocky Mountain Health PlansPolicy CSRAD022OH.E

UN-CSRAD022OH.E - Pediatric Pelvis Imaging Guidelinesopen_in_new

State-specific (Ohio) UnitedHealthcare Community Plan clinical guideline V1.0.2026 defining appropriate use, clinical documentation requirements, modality-specific guidance (US, CT, MRI, PET), coding/billing guidance, and condition-specific pelvis imaging sections for pediatric patients (≤18 years). Applies only to Ohio and ties medical necessity evaluation to Ohio Administrative Code 5160-1-01 for unproven/limited services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUN-CSRAD022OH.E - Pediatric Pelvis Imaging Guidelinesopen_in_new

Policy CodePolicy CSRAD022OH.E

Change TypeVersioning updated to v1.0.2026

Effective DateFeb 3, 2026

Next Review Date

Key ActionProviders must submit detailed history, physical exam, relevant lab studies, and prior imaging to establish medical necessity.

SourceLink

POLICY UPDATE CHANGES

Versioning updated to v1.0.2026 with pediatric-specific guidance aligned to adult guidelines in referenced sections.

V1.0.2026Guideline Version

OhioGeographic Scope

≤18Pediatric Age Scope

7Pediatric topics

Coverage Summary

This document is the state-specific (Ohio) Pediatric Pelvis Imaging Guideline: V1.0.2026 (Guideline Number: CSRAD022OH.E, Effective Date: February 3, 2026). It applies only to the state of Ohio and ties determinations for unproven or limited services to Ohio Administrative Code 5160-1-01. The guideline is intended to guide appropriate pediatric pelvis imaging selection, required clinical documentation, modality- and coding-specific guidance (US, CT, MRI, PET, 3D rendering), and condition-specific recommendations for individuals age ≤18 years. These guidelines are evidence-based, reviewed formally on an annual cadence, and subject to interim updates as needed.

Key metadata

Guideline VersionV1.0.2026

Geographic ScopeOhio only

Pediatric Age Scope≤18 years

Pediatric imaging topics in part7

References cited across sectionsMultiple peer‑reviewed and practice-parameter references listed in Preface references (e.g., refs 1-23) and section reference lists

Effective DateFebruary 3, 2026

StatusCURRENT

Medical-Necessity Criteria

General Clinical Documentation and Age Considerations

Imaging is supported when clinical evaluation and documentation meet guideline expectations:

General clinical evaluation and age considerations

Documentation expectations: Advanced imaging or designated procedures should not be ordered prior to clinical evaluation by the treating physician or appropriate consultant, except for guideline-supported scheduled follow-up imaging; meaningful technological contact (telehealth, phone, message) by an established provider can serve as pertinent clinical evaluation; medical records pertinent to the requested imaging must be submitted to establish medical necessity.
Spine and Musculoskeletal guidelines require x-ray studies from when current episode of symptoms started or changed (if applicable).

Investigational/Experimental Studies

Services considered investigational/experimental/unproven when ANY of the following are present:

Investigational / Experimental criteria:

Coding

3D Rendering Codes (guidance and clinical scenarios)CPT

76376	3D rendering not requiring image post-processing on an independent workstation
76377	3D rendering requiring image post-processing on an independent workstation

Imaging Guidance Procedure CodesCPT

19085	Biopsy, breast, with placement of breast localization device(s), including MR guidance; first lesion
19086	Biopsy, breast... each additional lesion, including MR guidance
75989	Imaging guidance for percutaneous drainage with placement of catheter (all modalities)
76942	Ultrasonic guidance for needle placement
77011	CT guidance for stereotactic localization
77012	CT guidance for needle placement
77013	CT guidance for and monitoring of parenchymal tissue ablation
77021	MR guidance for needle placement
77022	MR guidance for and monitoring of parenchymal tissue ablation

Unlisted Procedure CodesCPT

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional)
78999	Unlisted procedure, diagnostic nuclear medicine

Medically Necessary - UltrasoundCPTCovered

76870	Scrotal ultrasound
76856	Ultrasound pelvis

Medically Necessary - Ultrasound DopplerCPTCovered

93975	Duplex scan of testicular/penile vasculature (Doppler) - listed as option
93976	Duplex scan, each extremity or region (alternative Doppler code listed)

Medically Necessary - MRICPTCovered

72195	MRI Pelvis without contrast
72197	MRI Pelvis without and with contrast
74183	MRI Abdomen without and with contrast (listed with pelvis for undescended testis)

Medically Necessary - CTCPTCovered

72193	CT Pelvis with contrast
74177	CT Abdomen and Pelvis with contrast

Medically Necessary - Nuclear MedicineCPTCovered

78730

Radiopharmaceutical urinary bladder residual study

Not Medically Necessary / ExcludedCPTNot Covered

scintigraphy

Scrotal scintigraphy / nuclear medicine for acute scrotum - stated as not medically necessary (no specific CPT listed)

Provider Actions & Billing Impact

Documentation Required

Submit Pertinent Clinical Records

Providers must submit detailed history, physical exam, relevant laboratory studies, and prior imaging to establish medical necessity. Condition-specific sections may describe additional documentation requirements.

Billing Rule

3D Rendering Billing and Prior Authorization

CPT 76376 and 76377 require documentation of concurrent physician supervision/participation for 3D post-processing and may require prior authorization even if the base imaging does not. These codes differ by whether an independent workstation is required.

76376
76377

Background, Evidence, and Definitions

These Pediatric Pelvis Imaging Guidelines are part of UnitedHealthcare's Cardiovascular and Radiology Imaging Guidelines (V1.0.2026) and are evidence-based. They evaluate advanced imaging modalities and procedures to provide clinical benefits focused on quality and patient safety. The guidelines are reviewed formally annually and may undergo interim updates; Policy History documents periodic evidence-based updates (including 02/01/2024, 07/01/2024, 05/01/2025, and 11/06/2025). The purpose is to guide appropriate imaging selection and documentation and to limit investigational, unproven, or experimental imaging and procedures.

Evidence	Details
Supporting references	Multiple peer-reviewed articles and practice parameters cited (ACR practice parameters, FDA communications on GBCAs), listed in Preface references 1-23
Policy History	Annual and interim evidence-based updates listed: 02/01/2024, 07/01/2024, 05/01/2025, 11/06/2025

Definitions:

Investigational/Experimental/Unproven — Services lacking sufficient evidence, clinical utility, or collective professional support, as described in the guideline (for example: paucity of supporting evidence; evidence not matured to demonstrate improved health outcomes; clinical utility not demonstrated; or lack of collective opinion of support).

Concurrent supervision (3D rendering) — Active physician participation in and monitoring of the image post-processing 3D reconstruction process, including design of the anatomic region to be reconstructed, determination of tissue types/structures to display, selection of images or cine loops to archive, and monitoring/adjustment of the 3D work product (as required for CPT 76376/76377).

Revision History

02/01/2024policy_update

Annual evidence-based updates (Policy History entry: 02/01/2024).

07/01/2024policy_update

Interim evidence-based updates (Policy History entry: 07/01/2024).

05/01/2025policy_update

Annual evidence-based updates (Policy History entry: 05/01/2025).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUN-CSRAD022OH.E - Pediatric Pelvis Imaging Guidelinesopen_in_new

Policy CodePolicy CSRAD022OH.E

Change TypeVersioning updated to v1.0.2026

Effective DateFeb 3, 2026

Next Review Date

Key ActionProviders must submit detailed history, physical exam, relevant lab studies, and prior imaging to establish medical necessity.

SourceLink

On This Page

Paucity of supporting evidence

Supporting evidence includes credible peer-reviewed literature; collective opinion of support includes specialty society recommendations.

Investigational / Experimental criteria: Evidence has not matured to exhibit improved health parameters

Investigational / Experimental criteria: Clinical utility has not been demonstrated in any condition

Investigational / Experimental criteria: Study, treatment, procedure, or device lacks a collective opinion of support

Modality Selection and Contrast Use - CT

CT contrast/level selection and substitution rules:

CT contrast selection - when to use without contrast: CT without contrast is appropriate when clinical criteria for CT with contrast are met AND the individual has elevated BUN/creatinine, renal insufficiency, allergies to iodinated contrast, thyroid disease treatable with I-131, diabetes, very elderly, urgent/emergent needs, or trauma

CT without contrast is also appropriate for structures with significant tissue density differences (lung, bone) or when contraindication to contrast exists.

CT with contrast - common uses: CT with contrast is commonly used when improved vascular or soft tissue resolution is needed, including characterization of malignancy, infectious and inflammatory conditions

CT without and with contrast - limited role: CT without and with contrast has a limited role; appropriate only in specific exceptions such as characterization of a mass, arterial/venous anatomy, or to better characterize findings on a very recent (within two weeks) inconclusive non-contrast CT

Risks of doubling radiation exposure generally outweigh benefits except for listed exceptions.

CT vs MRI substitution: CT should not replace MRI solely to avoid sedation unless supported in condition-specific guideline

Modality Selection and Contrast Use - MRI

MRI selection and contrast-use principles:

MRI preference and contraindications: MRI may be preferred in individuals with renal failure and those allergic to IV CT contrast; a CT is medically necessary in place of MRI when MRI criteria are met AND there is a contraindication to MRI (e.g., pacemaker, ICD, insulin pump, neurostimulator)

When replacing MRI with CT, match contrast level: MRI without contrast → CT without contrast; MRI without and with contrast → CT with contrast or CT without and with contrast.

Gadolinium use principles: Gadolinium use should be limited to circumstances where additional information is necessary; assess necessity of repetitive GBCAs; gadolinium is relatively contraindicated during pregnancy unless benefit outweighs fetal risk

Gadolinium exposure linked to NSF in renal failure and potential deposition concerns; follow FDA guidance and limit repetitive use.

MRI superiority and appropriate uses: MRI is superior for soft tissues, brain/spinal cord, musculoskeletal soft tissue masses, and evaluating inconclusive ultrasound or CT findings

MRI typically performed without and with contrast (CPT 72197) unless contraindicated; consider anesthesia planning in pediatric patients to minimize exposures.

Ultrasound Use

Ultrasound indications and limitations:

Indications for ultrasound: Indications include obstetric/gynecologic imaging, soft tissue and visceral imaging of chest/abdomen/pelvis/extremities, brain and spine when not obscured by bone, vascular imaging when not obscured by bone, procedural guidance, and initial evaluation of ill-defined soft tissue masses

Transabdominal ultrasound is appropriate in all pediatric individuals; transvaginal ultrasound appropriate only in sexually active pediatric individuals who consent.

Limitations of ultrasound: Ultrasound is operator-dependent and limited in areas with dense bone or for very large abnormalities

Ultrasound may be of limited value for very large abnormalities and requires proper training for consistent high-quality evaluations.

Ultrasound role prior to advanced imaging: Ultrasound is often beneficial prior to advanced imaging to select appropriate modality and sequences

For many pelvic conditions ultrasound should be the initial imaging to rule out situations that do not require additional advanced imaging.

PET Use

PET imaging principles:

PET surveillance and modality bundling: PET is not medically necessary for surveillance imaging unless specifically stated in condition-specific guideline sections; PET/MRI is generally not supported; unbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported

PET/CT is typically done as a single study and unbundling may be denied.

PET characteristics: PET lacks the tissue definition of CT or MRI but provides metabolic information based on the radiotracer; PET is rarely performed as a single modality and is typically combined with CT

Indications include oncologic, cardiac, and some brain imaging where metabolic activity assessment is required.

Overutilization Safeguards

Appropriateness criteria to prevent unnecessary imaging:

Obtain prior results: Obtain results of initial diagnostic tests/imaging before performing further advanced imaging

Review of prior imaging histories can avoid duplicate or unnecessary studies.

Clinical history requirement: Clinical history should include a potential indication or known/suspected abnormality involving the body part to be imaged

Requested imaging should be expected to impact management or treatment decisions.

Limit repeat imaging: Repeat imaging not generally necessary unless disease progression, recurrence, or repeat imaging will affect clinical management

Pre-operative imaging is not medically necessary if the planned surgery/procedure is not medically necessary.

Undescended Testis - Medically Necessary Imaging

After surgical evaluation or consultation, the following imaging is medically necessary for pre-operative evaluation:

Initial and conditional imaging for undescended testis: Scrotal ultrasound (CPT 76870) if testis not palpable in the scrotal sac and there is concern for retractile or inguinal testis

Suspected undescended testis should prompt referral to a surgical subspecialist who decides on necessary imaging.

Advanced imaging after inconclusive ultrasound or if it would alter surgery: If ultrasound is inconclusive or the surgical consultant indicates advanced imaging would significantly alter the surgical procedure, MRI Abdomen (CPT 74183) and Pelvis (CPT 72197) without and with contrast OR CT Abdomen and Pelvis with contrast (CPT 74177) are medically necessary

In general CT and MRI are not medically necessary to localize non-palpable testes as findings typically do not alter the surgical procedure.

Scrotal Pathology - Medically Necessary Imaging

Pediatric-specific indications and choices for scrotal imaging:

Torsion evaluation: Scrotal ultrasound (CPT 76870) with Doppler (CPT 93975 or CPT 93976) is medically necessary for concerns of testicular torsion

Ultrasound with Doppler is the primary imaging for acute scrotum evaluation.

When MRI is appropriate: MRI Pelvis without contrast (CPT 72195) or without and with contrast (CPT 72197) is medically necessary if torsion is unlikely on ultrasound and no surgical exploration is planned

MRI is not typically used for the acute scrotum due to limited availability and long exam time.

Scintigraphy exclusion: Scintigraphy (testicular nuclear medicine) is not medically necessary for evaluation of the acute scrotum

Doppler ultrasound acceptance and scintigraphy limitations (radiation, poor anatomic detail, time) support this exclusion.

Patent Urachus - Imaging Pathway

Initial and follow-up imaging indications for suspected patent urachus:

Initial imaging: Ultrasound pelvis (CPT 76856) is medically necessary as the initial evaluation for patent urachus

Ultrasound has an accuracy greater than 90% for urachal anomalies.

Advanced imaging if ultrasound inconclusive: ANY of the following are medically necessary if the ultrasound is inconclusive or insufficient for preoperative planning: MRI Pelvis without contrast (CPT 72195); MRI Pelvis without and with contrast (CPT 72197); CT Pelvis with contrast (CPT 72193)

Repeat imaging of asymptomatic individuals is not generally necessary unless new/worsening symptoms or for preoperative planning.

Periurethral Cysts / Urethral Diverticula and Fetal MRI / Penis-Soft Tissue Mass / Incontinence

Statements of parity with adult imaging indications and pediatric-specific notes:

Parity statements: Periurethral cysts and urethral diverticula, fetal MRI, and penile soft tissue mass imaging indications in pediatric individuals are identical to adults

See referenced adult guideline sections (PV-13, PV-15.1, PV-18.1).

Incontinence imaging specifics: Incontinence imaging indications are very similar to adults; no imaging needed if primary enuresis is suspected — obtain full history and urinalysis first; radiopharmaceutical urinary bladder residual study (CPT 78730) is medically necessary for suspicion of urinary retention and a recent non-diagnostic ultrasound

If ultrasound is inconclusive or spinal abnormality is suspected, MRI Pelvis without and with contrast (CPT 72197) is medically necessary; CT Pelvis with contrast (CPT 72193) appropriate if MRI not readily available.

Billing Rule

Guidance Codes Bundling and Units

Guidance procedure codes include the imaging necessary to guide needle or catheter placement and should not routinely be billed with a separate diagnostic procedure. Only one unit of any guidance code should be reported per individual encounter (date of service).

77012
77021
76942
77002
77003

Billing Rule

Appropriate Use of CPT 77011 vs Diagnostic CT

Report CPT 77011 when a stereotactic localization CT scan is performed that does not require radiologist interpretation. If a diagnostic CT is interpreted by a radiologist, report the diagnostic CT code instead. It is not appropriate to report both 77011 and a diagnostic CT code for the same CT session.

77011
70486

Denial Risk

Unbundling PET/CT Not Supported

Unbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported and claims for separate PET and diagnostic CT codes may be denied.

Documentation Required

Surgical consultation prior to advanced imaging for undescended testis

Suspected undescended testis should prompt referral to a surgical subspecialist; advanced imaging (e.g., MRI abdomen and pelvis or CT abdomen and pelvis) is medically necessary only after surgical evaluation or consultation indicates the imaging would alter the procedure.

76870
74183
72197
74177

Documentation Required

History and urinalysis prior to incontinence imaging

Obtain a full medical history and urinalysis before imaging for incontinence. No imaging is needed if primary enuresis is suspected. Use MRI pelvis without and with contrast or CT pelvis with contrast only as indicated after these initial evaluations.

72197
72193
78730

Billing Rule

Use ultrasound as initial study for patent urachus

Ultrasound pelvis (CPT 76856) is the medically necessary initial evaluation for suspected patent urachus. Advanced imaging (MRI pelvis or CT pelvis) is reserved for cases where ultrasound is inconclusive or insufficient for preoperative planning.

76856
72195
72197
72193

Denial Risk

CT/MRI to locate non-palpable testes generally not necessary

CT and MRI to localize non-palpable testes are generally not medically necessary because findings typically do not alter the surgical procedure and such imaging may be denied unless the surgical consultant indicates the imaging would significantly alter the procedure.

74183
72197
74177

11/06/2025policy_update

Annual evidence-based updates; periodic evidence-based updates through 11/06/2025 noted for pediatric modules (PEDPV-9.1 through PEDPV-15.1).

v1.0.2026versioningLatest

Versioning updated to V1.0.2026 with pediatric-specific guidance aligned to adult guidelines; Pediatric Pelvis Imaging Guidelines effective February 3, 2026 (V1.0.2026).