CurrentColorado Rocky Mountain Health PlansPolicy CSRAD022OH.E

Pediatric Pelvis Imaging Guidelines (For Ohio Only)

Clinical guideline specifying advanced imaging appropriateness for pediatric pelvis conditions for Ohio providers and payers; governs medical necessity review for imaging requests under Ohio Administrative Code 5160-1-01.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPediatric Pelvis Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD022OH.E

Change TypeNo material change

Effective DateFeb 3, 2026

Next Review DateN/A

Key ActionSubmit pertinent clinical evaluation and prior imaging when requesting advanced pelvic imaging to establish medical necessity and avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

V1.0.2026guideline version

Ohiojurisdiction

Yesclinical doc required

US-firstinitial modality

Annualreview cadence

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Coverage Criteria — Pediatric Pelvis Imaging

Imaging pathway and repeat imaging

Covered when ALL of the following pathway and repeat-imaging principles are met:

ALL of the following

A pertinent clinical evaluation since the onset or change in symptoms has been performed and documented, including detailed history, physical examination, appropriate laboratory studies, and basic imaging (for example plain radiography or ultrasound) prior to advanced imaging unless the individual is undergoing guideline-supported scheduled follow-up imaging.
A meaningful technological contact (telehealth, telephone, electronic messaging) may substitute for face-to-face evaluation when appropriate; some conditions may still require face-to-face evaluation per condition-specific guidance.
The results of prior diagnostic tests or radiologic studies relevant to the current clinical question have been reviewed and documented to avoid unnecessary duplicate imaging.
Obtain initial diagnostic or radiologic results before performing further advanced imaging when feasible.
The requested repeat imaging is expected to affect clinical management, treatment decisions, or surgical planning, or there is documented evidence of disease progression or new/worsening symptoms since the prior study.
Routine repeat imaging of asymptomatic individuals is generally not supported.
When advanced imaging is requested after an initial ultrasound, the ultrasound findings are inconclusive, indeterminate, or insufficient to answer the clinical question, and the advanced modality selected is appropriate for the condition per modality guidance (e.g., MRI preferred for soft tissue characterization; CT when MRI is unavailable or contraindicated).
Ultrasound is the initial imaging modality for most pediatric pelvic conditions and can guide modality selection for advanced imaging.
For pediatric MRI under anesthesia, if intravenous access and no contraindication to contrast exist, consider obtaining both non-contrast and contrast sequences in the same anesthesia session when guideline-supported to minimize anesthesia exposures and avoid repeat studies.
Plan MRI sessions to minimize anesthesia exposure; obtain all necessary body areas concurrently if clinically supported.
Pre-operative or pre-procedural imaging is medically necessary only when the planned surgery/procedure itself is medically necessary; if the procedure is not medically necessary, associated pre-operative imaging is not medically necessary.
Once the procedure is approved or does not require prior authorization, appropriate pre-procedural imaging may be approved.
When using CT, avoid routine use of CT without and with contrast (double contrast) unless specifically indicated for characterization of a mass, arterial/venous anatomy, or other guideline-supported exceptions; balance radiation exposure with diagnostic benefit.
CT protocols should be tailored for pediatric patients rather than using adult CT settings.
Repeat imaging may be medically necessary for: new or worsening symptoms, evidence of disease progression or recurrence, or to inform preoperative planning; otherwise repeat studies are discouraged.
Document clinical rationale for repeat imaging in the request to support medical necessity.

Covered Indications and Modality Selection

Modalities by clinical scenario

Ultrasound indications: Obstetric/gynecologic imaging, soft tissue and visceral pelvic evaluation, vascular imaging when not obscured by bone, procedural guidance, and initial evaluation of masses or adenopathy; ultrasound often guides selection of further advanced imaging.

Operator-dependent; proper training recommended.

CT indications: Trauma screening, evaluation of abdominal/pelvic viscera, complex fractures, and when ultrasound/MRI are inconclusive or contraindicated; select contrast level per indication.

Avoid routine double-contrast CT except for limited indications.

MRI indications: Characterization of soft tissue masses, musculoskeletal soft tissues, infections, and when ultrasound is inconclusive or better soft tissue definition is required; perform MRI without and with contrast when indicated.

Consider anesthesia needs in young children and limit GBCA use to circumstances where additional information is necessary.

3D rendering for complex pelvic conditions or when conventional imaging is insufficient

3D rendering pelvic indications: Consider 3D rendering (CPT 76376/76377) for complex pelvic conditions or when conventional imaging is insufficient (e.g., uterine intra‑cavitary lesions with equivocal US, hydrosalpinx or peritoneal cysts when US indeterminate, lost IUD with inconclusive US, uterine anomalies, infertility workup).

Document physician supervision/participation when reporting 3D rendering codes.

Imaging guidance for tumor ablation

Ablation guidance indication: Use CPT 77013 (CT) or CPT 77022 (MR) for percutaneous non-bone tumor ablations where imaging guidance, monitoring for repositioning, and confirmation of coagulative necrosis are required; for bone ablations use CPT 20982.

Only one unit of these guidance codes should be reported per individual encounter.

Whole-body CT for multiple myeloma staging

Whole-body CT for multiple myeloma: Whole-body low-dose skeletal CT is supported for oncologic staging in multiple myeloma.

Whole-body CT screening of asymptomatic individuals is not covered except as specified for staging in multiple myeloma.

Whole-body MRI selective indications

WBMRI selective indications: WBMRI may be approved for interval cancer screening in select cancer predisposition syndromes or for certain autoimmune indications (e.g., chronic recurrent multifocal osteomyelitis); otherwise WBMRI is generally not supported.

Report WBMRI using CPT 76498 when appropriate.

Abnormal uterine bleeding

AUB imaging pathway: Transabdominal ultrasound first-line for abnormal uterine bleeding; transvaginal ultrasound only for sexually active/tampon‑using pediatric individuals who consent; MRI pelvis (72195 or 72197) is medically necessary if ultrasound is inconclusive.

Lymphatic mapping / lower extremity lymphedema

Lymphatic mapping indication: Lymphatic mapping (CPT 78195) is medically necessary for lower-extremity lymphedema with a recent negative Doppler ultrasound, or with a history of Milroy's disease or prior pelvic lymph node dissection.

Pelvic inflammatory disease

PID imaging: Transabdominal ultrasound is appropriate in all pediatric individuals; transvaginal ultrasound appropriate for sexually active/tampon-using individuals who consent; MRI pelvis (72195/72197) is medically necessary if ultrasound is inconclusive; CT pelvis with contrast (72193) if MRI not available.

Amenorrhea

Amenorrhea imaging: Evaluate primary amenorrhea initially with pelvic ultrasound (76856 or 76857); transvaginal ultrasound (76830) is appropriate for sexually active females; MRI pelvis and/or MRI abdomen (72195/72197/74181/74183) are medically necessary for congenital anomalies or preoperative planning.

Endometriosis

Endometriosis imaging: Transabdominal ultrasound is appropriate in all pediatric individuals; transvaginal ultrasound is appropriate only for sexually active/tampon-using individuals who consent and is not generally appropriate in pre-pubescent or never sexually active individuals.

Suspected adnexal mass

Suspected adnexal mass: Ultrasound is first-line (transabdominal for all; transvaginal for sexually active/tampon‑using individuals who consent); adnexal masses with solid component in individuals age ≥15 should follow pediatric germ cell tumor imaging guidance.age >= 15

Ovarian torsion / acute pelvic pain

Ovarian torsion / acute pelvic pain: Transabdominal ultrasound (76856) with Doppler (93975) is appropriate in all pediatric individuals; transvaginal ultrasound with Doppler is appropriate for sexually active/tampon‑using individuals who consent.

MRI pelvis may be used if ultrasound inconclusive and no surgical exploration planned.

Polycystic ovary syndrome

Polycystic ovary syndrome: Transabdominal ultrasound (76856) is appropriate; transvaginal ultrasound (76830) is appropriate only for sexually active/tampon‑using individuals who consent; correlate imaging with laboratory studies because ovarian morphology alone is insufficient for diagnosis in adolescents.

PCOS imaging

PCOS ultrasound indication: Transabdominal ultrasound appropriate for all pediatric individuals suspected of PCOS; transvaginal ultrasound appropriate only if sexually active or tampon use with consent.

Undescended testis localization

Undescended testis ultrasound indication: Scrotal ultrasound (76870) is medically necessary if the testis is not palpable and there is concern for retractile or inguinal testis after surgical consultation.

Referral to a surgical subspecialist is indicated prior to imaging.

Suspected testicular torsion

Torsion imaging indication: Scrotal ultrasound with Doppler (76870 + 93975/93976) is medically necessary for suspected testicular torsion.

Patent urachus evaluation

Patent urachus initial imaging: Ultrasound pelvis (CPT 76856) is the initial medically necessary study for suspected patent urachus.

Suspected patent urachus and preoperative planning

Suspected patent urachus pathway: For suspected patent urachus perform initial ultrasound (CPT 76856); if ultrasound is inconclusive or insufficient for preoperative planning, escalate to MRI pelvis (72195 or 72197) or CT pelvis with contrast (72193); repeat imaging of asymptomatic individuals is generally not necessary unless new/worsening symptoms or preoperative planning are indicated.

Ultrasound accuracy for urachus evaluation is >90%.

Coding — CPT and Procedure Codes

3D RenderingCPTCovered

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

MRI-guided breast biopsyCPTCovered

19085	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including MR guidance
19086	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including MR guidance

Imaging guidance / stereotactic / ablationCPTCovered

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

Guidance and procedure codesCPT

77013	CT guidance for percutaneous procedures (includes needle electrode direction, monitoring repositioning, multiple ablations, confirmation of coagulative necrosis) — use only for non-bone ablations
77022	MR guidance for percutaneous procedures (includes initial guidance, monitoring repositioning, multiple ablations, confirmation)
20982	CT guidance for bone tumor ablations (note: CPT 77013 should not be used for bone ablation)
77012	Radiologic guidance code (alternate modality)
77021	Radiologic guidance code (alternate modality)
76942	Ultrasound guidance
77002	Fluoroscopy guidance code range (77002-77003 referenced)
77003	Fluoroscopy guidance code range (77002-77003 referenced)

Unlisted procedure codesCPT

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional); used for whole-body MRI reporting
78999	Unlisted diagnostic nuclear medicine procedure

Limited CTCPTExperimental

76380

Limited or follow-up CT scan (used when full diagnostic work not performed); not medically necessary for treatment planning

Limited CT (classification)CPT

No codes listed

SPECT/CT and hybrid nuclear/CTCPT

78830	Hybrid SPECT/CT, single area, single day
78831	Hybrid Nuclear/CT, 2 or more days
78832	Hybrid Nuclear/CT, 2 areas with one day and 2-day study
78072	SPECT/CT parathyroid nuclear imaging (effective 2013)

Secondary interpretationCPT

76140

Interpretation of an exam completed at another facility (secondary interpretation)

PET/MRI reporting codesCPT

78813

PET Whole-Body (used in PET/MRI reporting when criteria met)

Pelvis MRI / CT / Guidance CodesCPT

72195	MRI Pelvis without contrast
72196	MRI Pelvis with contrast
72197	MRI Pelvis without and with contrast
76498	Unlisted MRI procedure (for radiation planning or surgical software)
72198	MRA Pelvis
74176	CT Abdomen and Pelvis without contrast
74177	CT Abdomen and Pelvis with contrast
74178	CT Abdomen and Pelvis without and with contrast
72192	CT Pelvis without contrast
72193	CT Pelvis with contrast

1–10 of 13

1/2

CTA / PET / Nuclear Medicine CodesCPT

77014	CT Guidance for Placement of Radiation Therapy Fields
76497	Unlisted CT procedure (for radiation planning or surgical software)
74174	CTA Abdomen and Pelvis
72191	CTA Pelvis
78811	PET limited area (not used in pediatrics)
78812	PET skull base to mid-thigh (not used in pediatrics)
78813	PET whole body (not used in pediatrics)
78814	PET with concurrently acquired CT; limited area (rarely used in pediatrics)
78815	PET with concurrently acquired CT; skull base to mid-thigh
78816	PET with concurrently acquired CT; whole body

1–10 of 16

1/2

Ultrasound and Duplex CodesCPT

78803	Radiopharmaceutical Localization Imaging SPECT
76856	Ultrasound, pelvic (nonobstetric), complete
76830	Ultrasound, pelvic transvaginal
76857	Ultrasound, pelvic (nonobstetric), limited or follow-up
76870	Ultrasound, scrotum and contents
93975	Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents; complete
93976	Duplex scan ... limited study
93978	Duplex scan of aorta/IVC/iliac; complete
93979	Duplex scan of aorta/IVC/iliac; limited
93980	Duplex scan of penile vessels; complete

1–10 of 11

1/2

Referenced imaging CPT codesCPT

76856	Transabdominal pelvic ultrasound (documented in guidance)
76857	Transabdominal pelvic ultrasound with Doppler or additional views (listed for amenorrhea)
76830	Transvaginal pelvic ultrasound (appropriate for sexually active pediatric individuals)
93975	Doppler study (used with ultrasound for ovarian torsion)
72195	MRI pelvis without contrast (medically necessary if ultrasound inconclusive)
72197	MRI pelvis without and with contrast (medically necessary if ultrasound inconclusive)
72193	CT pelvis with contrast (medically necessary if MRI not readily available)

Initial/appropriate ultrasound CPT codesCPTCovered

76856

Transabdominal pelvic ultrasound

Transvaginal ultrasoundCPTCovered

76830

Transvaginal ultrasound

Scrotal ultrasound and DopplerCPTCovered

76870	Scrotal ultrasound
93975	Doppler ultrasound (arterial) — referenced as Doppler for scrotal evaluation
93976	Doppler ultrasound (venous) — referenced as Doppler for scrotal evaluation

Advanced imaging and nuclear medicineCPTCovered

72195	MRI Pelvis without contrast
72197	MRI Pelvis without and with contrast
74183	MRI Abdomen without and with contrast
74177	CT Abdomen and Pelvis with contrast
72193	CT Pelvis with contrast
78730	Radiopharmaceutical urinary bladder residual study

Initial covered CPT CodesCPTCovered

76856

Ultrasound pelvis

Second-line/advanced imaging CPT CodesCPTCovered

72195	MRI pelvis without contrast
72197	MRI pelvis without and with contrast
72193	CT pelvis with contrast

Guidance code units per encounter

Guidance units per encounterOnly one unit of guidance codes (e.g., 77013, 77022, 77012, 77021, 76942, 77002-77003) should be reported per individual encounter (date of service)

Unit definitionThe unit of service is the individual encounter, not the number of lesions, aspirations, biopsies, injections, or localizations

Applies to modalitiesApplies to CT, MR, ultrasound, and fluoroscopy guidance codes listed (e.g., 77013, 77022, 76942, 77012)

Anesthesia requirement by age

Anesthesia typical age cutoffAnesthesia is usually required for almost all infants (except neonates) and young children age <7 years

Older children with delaysAnesthesia is also usually required for older children with delays in development or maturity

Anesthesia route and planningAnesthesia may be administered orally or intravenously; plan MRI sessions to minimize repeat anesthesia (perform without-and-with-contrast in same session when appropriate)

Provider Actions — Authorization, Documentation, and Escalation

Prior Authorization

Medical necessity and prior authorization requirements

Advanced imaging and other designated procedures may require prior authorization and adequate clinical documentation to establish medical necessity. Submit a pertinent clinical evaluation since onset or change in symptoms, including detailed history, physical exam, relevant laboratory studies, and prior imaging results. Advanced imaging should generally be ordered only after initial clinical evaluation (including appropriate basic imaging such as plain radiography or ultrasound) or documented specialist consultation; meaningful technological contact (telehealth, telephone, electronic messaging) may suffice when appropriate. These guidelines are evidence-based but do not replace physician judgment; if physician judgment overrides the guideline, document the clinical rationale.

Provide documentation of history, exam, labs, and prior imaging when submitting requests for advanced imaging.
State how the requested imaging will affect management or treatment decisions.
Clinical surveillance exceptions (scheduled follow-up) are addressed in condition-specific sections.

Prior Authorization

Prior authorization expectations and denial triggers

Prior authorization is commonly expected for advanced pelvic imaging when ultrasound is inconclusive or when the study is escalation from initial imaging. Requests lacking adequate clinical information, duplicative imaging without indication of progression, or imaging unlikely to affect management are at risk for denial. If advanced imaging is requested instead of performing the recommended initial ultrasound, document the clinical reasoning and why ultrasound was not performed. For MRI pelvis ordered without prior ultrasound, include rationale and prior imaging to justify escalation.

Advanced MRI (CPT 72195, 72197) or CT (CPT 72193) may require prior authorization.
Document initial ultrasound results and the specific rationale for escalating to MRI/CT.
Denial triggers: inadequate clinical info, duplicative studies without new findings, imaging unlikely to change management.

Documentation Required

PET/MRI reporting requirement

PET/MRI is reportable only when criteria are met and should be documented and authorized as appropriate. When PET/MRI is supported, report using the combination PET Whole-Body (CPT 78813) plus MRI unlisted (CPT 76498). Ensure prior authorization aligns with condition-specific PET/CT criteria or institution availability.

PET/MRI is medically necessary only when either condition-specific PET/MRI criteria are met, or ALL: the individual meets PET/CT criteria, PET/CT is unavailable, and the provider requests PET/MRI in lieu of PET/CT.
Report PET/MRI as CPT 78813 + CPT 76498; other reporting methods are inappropriate.
Diagnostic MRI codes may be appropriate concurrently when clinically indicated.

Prior Authorization

Prior authorization risk and documentation for 3D rendering (CPT 76376/76377)

3D rendering codes (CPT 76376, 76377) require documentation of concurrent physician supervision/participation per ACR recommendations and may require separate prior authorization even when the base imaging exam is not subject to prior authorization. Do not use these codes for 2D reformatting. Document the physician's role in design, tissue selection, archived outputs, and monitoring of reconstruction.

CPT 76376 — 3D rendering without independent workstation.
CPT 76377 — 3D rendering requiring an independent workstation.
Providers may need to obtain prior authorization for CPT 76376/76377 even if the underlying ultrasound/echo exam is not pre-authorized.

Billing Rule

Coding, unlisted procedures, secondary interpretation, and limited CT

Billing and coding rules: report secondary reinterpretation of outside imaging using CPT 76140 and document the secondary interpretation. For unlisted CT/MR studies or whole-body MRI scenarios where no specific CPT exists, use CPT 76497 (CT unlisted) or CPT 76498 (MRI unlisted) as appropriate; prefer Category III codes when available. Limited CT (CPT 76380) is not medically necessary for treatment planning and should not be used to cover extra slices or for planning purposes.

Use CPT 76140 for secondary interpretation of externally performed exams.
Report unlisted CT/MR with CPT 76497/CPT 76498 when no anatomic-specific code applies; use Category III codes instead of unlisted codes when available.
Do not report CPT 76380 for treatment planning; CPT 76380 is inappropriate to represent extra slices.

Step Therapy

Imaging modality sequencing and stepwise approach

Stepwise imaging and modality sequencing are expected: ultrasound (transabdominal or scrotal) is the first-line imaging modality for most pediatric pelvic conditions. If ultrasound is inconclusive or insufficient for preoperative planning, MRI pelvis (CPT 72195 without contrast or CPT 72197 without and with contrast) is appropriate next. If MRI is not readily available, CT pelvis with contrast (CPT 72193) may be medically necessary. For specific conditions (e.g., amenorrhea, PID, patent urachus, scrotal pathology), follow the condition-specific pathways.

Transabdominal ultrasound (CPT 76856 or CPT 76857) is appropriate for all pediatric individuals; transvaginal ultrasound only for sexually active adolescents who consent.
If ultrasound is inconclusive: MRI pelvis (CPT 72195 or 72197) is preferred; CT pelvis with contrast (CPT 72193) if MRI unavailable.
For suspected patent urachus, ultrasound is the initial study; MRI or CT only if ultrasound inconclusive.

Documentation Required

Required documentation when escalating from ultrasound to advanced imaging

Required documentation for imaging escalation or prior authorization requests: include the initial ultrasound report (with findings and limitations), specific clinical question to be answered by advanced imaging, documentation of how results would change management or surgical planning, and any surgical consultation notes when relevant (e.g., suspected undescended testis). For pediatric MRI requiring anesthesia, note the plan to minimize anesthesia exposures (obtain studies of multiple body areas in the same session when applicable).

Attach initial ultrasound images/reports and explain why they are inadequate for clinical decision-making or operative planning.
Explain the specific management decision that will be impacted by the advanced imaging.
Include surgical consult documentation when imaging is requested to inform operative approach (e.g., undescended testis).
If MRI under anesthesia is planned, document reasoning and efforts to consolidate imaging to a single session.

Definitions and Terms

Pertinent clinical evaluation

Pertinent clinical evaluationDetailed history, physical exam, appropriate laboratory studies, and appropriate prior imaging since onset or change in symptoms must be submitted

Provider evaluation before imagingAdvanced imaging or other designated procedures should not be ordered prior to clinical evaluation by the treating physician or consultant (meaningful technological contact may substitute)

Condition-specific additionsCondition-specific guideline sections may require additional clinical information (e.g., spine guidelines require x-rays)

Completion study — definition

Completion study definedAn MRI completion study refers to performing MRI with contrast only to better characterize findings on a recent inconclusive non-contrast MRI

Typical useCompletion studies are used when non-contrast MRI is inconclusive and targeted contrast-enhanced sequences are needed

Contrast considerationsMRI contrast is relatively contraindicated in pregnancy and GBCA use should be limited to when additional information is necessary

Ultrasound — diagnostic definition

Ultrasound definitionDiagnostic ultrasound uses high-frequency sound waves to evaluate soft tissue structures and vascular structures using grey scale and Doppler techniques

CapabilitiesProvides dynamic real-time bedside imaging and is useful for obstetric/gynecologic, soft tissue, visceral, vascular, and procedural guidance

LimitationsLimited in areas with dense bone or very large abnormalities and is operator-dependent

Concurrent supervision (3D rendering)

Concurrent supervision (3D rendering)Active physician participation and monitoring of the reconstruction process including design of the anatomic region, determination of tissue types/structures to display, selection of images to archive, and monitoring/adjustment of the 3D work product

DocumentationACR recommends documenting the physician's supervision or participation when reporting CPT 76376/76377

Workstation distinction76377 requires post-processing on an independent workstation; 76376 does not

Imaging guidance codes — definition & billing

Imaging guidance codes definedGuidance procedure codes (CT, MR, US, fluoroscopy) contain all imaging necessary to guide a needle or catheter during percutaneous interventions and should not routinely be billed with separate diagnostic procedure codes

ExamplesIncludes codes such as 76942 (US guidance), 77012/77021 (CT/MR needle placement), 77013/77022 (ablation monitoring), and 75989 (percutaneous drainage with catheter)

Billing noteIt is inappropriate to routinely bill a diagnostic procedure code in conjunction with a guidance procedure code

Guidance code definitions — 77013 / 77022

77013 / 77022 descriptionCPT 77013 (CT) and CPT 77022 (MR) include initial guidance to direct needle electrode, monitoring for repositioning, multiple ablations, and confirmation of coagulative necrosis for non-bone ablations

Bone ablation noteUse CPT 20982 for CT guidance of bone tumor ablations; 77013 should only be used for non-bone ablations

Unit reportingOnly one unit of these guidance codes should be reported per individual encounter (date of service)

CPT 76497 / 76498 — unlisted CT/MR guidance

Use of CPT 76497 / 76498CPT 76497 (unlisted CT) or CPT 76498 (unlisted MR) should be reported when no anatomic site-specific code exists, including whole-body MRI reporting

Category III guidanceIf a Category III code exists that describes the procedure, report the Category III code rather than an unlisted code

Appropriate scenariosUsed for navigation/planning for neurosurgery, custom joint arthroplasty planning, or procedures needing different positional acquisition or thinner cuts

Pediatric — age cutoff

Pediatric age cutoffPediatric is defined as individuals age 18 years or younger for application of the Pediatric Pelvis Imaging Guidelines

Adults defaultIndividuals >19 years should be imaged according to the General Pelvis Imaging Guidelines unless otherwise directed

Age-based management differencesManagement may differ between pediatric and adult populations due to age, comorbidities, and disease natural history

MRI pelvis — contrast use (72197 guidance)

MRI pelvis contrast guidanceMRI pelvis without and with contrast (CPT 72197) is generally performed unless there is a documented contraindication to gadolinium

When to perform without vs with contrastMRI pelvis without contrast (72195) may be used when contrast contraindicated or when appropriate per condition-specific guidance; perform without-and-with-contrast in same anesthesia session when possible

Contraindications and cautionGadolinium relatively contraindicated in pregnancy; limit GBCA use to circumstances where additional information is necessary

Primary amenorrhea — definition

Primary amenorrhea definitionPrimary amenorrhea refers to absence of menstrual periods by age 16

Clinical evaluationEvaluate with pelvic ultrasound and consider MRI for congenital anomalies or preoperative planning as appropriate

DocumentationDocument normal pubertal development and pregnancy test results when relevant

Urachus / Patent urachus — definition

Urachus definitionThe urachus is a fetal connection between the bladder and the umbilicus that normally obliterates; persistence can be complete or partial

Clinical relevancePersistent (patent) urachus may require imaging for diagnosis and preoperative planning

Ultrasound accuracyUltrasound evaluation for urachus has an accuracy greater than 90%

Patent urachus — definition (alternate)

Patent urachus definitionPatent urachus is a persistent tubular connection between the fetal bladder and the umbilicus resulting from failure of normal obliteration

Imaging implicationsInitial evaluation with ultrasound is recommended; escalate to MRI or CT if ultrasound is inconclusive or insufficient for preoperative planning

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

Not Covered and Exclusions

PET/MRI is generally not supported for most oncologic and neurologic indications. When PET/MRI is requested in lieu of PET/CT, unbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported. If PET/MRI is considered appropriate under condition‑specific guidance or when PET/CT is unavailable and PET/MRI is requested as an alternative, report PET/MRI using CPT 78813 (PET whole‑body) plus CPT 76498 (unlisted MR) and ensure prior authorization when required.

Misuse of 3D rendering includes reporting CPT 76376/76377 for routine 2D reformatting or in conjunction with procedures that already generate 3D datasets (for example, stereotactic localization CPT 77011/70486, CTA, MRA, PET/CT). CPT 77021 is not appropriate for MRI‑guided breast biopsy; use CPT 19085 for the first lesion and CPT 19086 for additional lesions as specified.

Whole‑body CT or MRI screening of asymptomatic individuals is not supported except for a few specified indications: whole‑body low‑dose skeletal CT is supported for staging in multiple myeloma, and interval WBMRI may be appropriate for select cancer predisposition syndromes or specific autoimmune conditions. Outside these limited exceptions, whole‑body screening exams are not covered.

Advanced imaging of the pelvis for asymptomatic screening is not covered. Imaging should be reserved for symptomatic individuals or those with findings where imaging results will change management.

Transvaginal ultrasound in pre‑pubescent pediatric individuals or in those who are not sexually active and do not use tampons is generally not appropriate. Use of transvaginal ultrasound is limited to sexually active or tampon‑using pediatric individuals who provide consent; documentation should reflect this when ordering and performing the study.

Scintigraphy for scrotal evaluation is not medically necessary and is discouraged for acute scrotal assessment. Doppler scrotal ultrasound (CPT 76870 with CPT 93975/93976) is the appropriate initial study for suspected torsion or other acute scrotal pathology.

OpenPayer

Pediatric Pelvis Imaging Guidelines (For Ohio Only)

Coverage Criteria — Pediatric Pelvis Imaging

Covered Indications and Modality Selection

Coding — CPT and Procedure Codes

Provider Actions — Authorization, Documentation, and Escalation

Prior Authorization Requirements

Contrast Use and Safety Considerations

Frequency Limits and Repeat Imaging

Background and Scope

Definitions and Terms

Not Covered and Exclusions