Colorado Rocky Mountain Health Plans Pediatric Pelvis Policy Update

Coverage Criteria and Condition-Specific Indications

Medical necessity and modality selection

Imaging is appropriate when based on clinical presentation and adequate prior evaluation; advanced imaging should answer a specific clinical question and affect management.

Clinical justification: Imaging requests must be based on the individual's clinical presentation and include a pertinent clinical evaluation since onset or change in symptoms (detailed history, physical exam, appropriate laboratory studies, and prior imaging when relevant).

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Impact on management: Requested imaging should be expected to affect clinical management or treatment decisions; scheduled guideline-supported surveillance imaging is an exception.

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Modality selection: Select modality to answer the specific diagnostic question: ultrasound for initial real-time soft tissue and vascular evaluation; CT for trauma, complex fractures, and abdominal/pelvic viscera evaluation; MRI for superior soft tissue characterization or when CT/US are inconclusive.

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Contrast and safety: Appropriate contrast level (none / with / without and with) should be chosen per indication; assess renal function (e.g., GFR) and pregnancy status prior to iodinated or gadolinium contrast use and limit GBCA exposure when not necessary.GFR <30 mL/min (special caution)

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Indications for 3D rendering

CPT 76376/76377 can be considered in the following clinical scenarios:

3D rendering indications: Consider CPT 76376 or 76377 for pre-operative planning and complex anatomic depiction when conventional imaging is insufficient, including: congenital skull abnormalities, complex fractures/dislocations (including spine, pelvic/acetabular, intra-articular fractures), complex facial fractures, cerebral angiography, pelvic indications such as uterine intracavitary lesions when ultrasound is equivocal, hydrosalpinx/peritoneal cysts when ultrasound is indeterminate, lost IUD when initial ultrasound is non-diagnostic, uterine anomalies, infertility evaluation; abdomen uses such as CT urogram and MRCP per referenced guidelines.

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Use and limitations of imaging guidance codes

Guidance procedure codes are appropriate when imaging is used to guide percutaneous procedures and include the following constraints:

Guidance code applicability: Guidance codes (e.g., CPT 77012, 77021, 76942, 77002-77003, 77013, 77022) include the imaging necessary to guide percutaneous needle or catheter procedures and should be used for percutaneous surgical procedures only (not open/excisional/incisional surgery).

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Billing constraints: Do not routinely bill a diagnostic procedure code in conjunction with a guidance procedure code; only one unit of a guidance code should be reported per individual encounter (the unit is the encounter, not number of lesions).1 unit per encounter

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Procedure-specific notes: Use modality-specific guidance codes appropriately (e.g., CPT 77012 for CT needle placement, CPT 77021 for MR needle placement, CPT 76942 for US guidance); CPT 77021 is not appropriate for breast biopsy (use CPT 19085/19086 as described).

Stereotactic CT localization

Stereotactic localization CT usage and billing:

When to report 77011: Report CPT 77011 for stereotactic CT localization scans performed as a technical-only service that do not require radiologist interpretation (commonly used for navigation/workstation datasets).

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Avoid duplicate reporting: Do not report both a diagnostic CT code and CPT 77011 for the same stereotactic localization session; if a diagnostic CT is interpreted by a radiologist, use the appropriate diagnostic CT code instead of 77011.

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3D rendering exclusion: Do not report CPT 76376 or CPT 76377 in conjunction with CPT 77011, as stereotactic localization inherently generates a 3D dataset.

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Coding and medical necessity rules

Coverage and coding rules include the following specific requirements and conditions

Ablation guidance codes: CPT 77013 (CT) and CPT 77022 (MR) include initial guidance, monitoring for repositioning, multiple ablations when needed, and confirmation of coagulative necrosis; CPT 77013 is limited to non-bone ablations and CPT 20982 covers CT guidance for bone ablations. These codes are for percutaneous procedures only and one unit per encounter applies.one unit per encounter

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Unlisted CT/MR use: Use CPT 76497 or 76498 when no anatomic site-specific CT or MR code exists (e.g., navigation/stealth imaging, custom joint arthroplasty planning, or when thinner cuts/positional acquisitions for surgical planning are required); prefer a Category III code if one is available. CPT 76498 is the reportable code for whole-body MRI.

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Limited CT restrictions: CPT 76380 describes a limited or follow-up CT but is not medically necessary for treatment planning and should not be used to report 'extra slices' or to substitute for a full diagnostic code when full diagnostic work is required.

General pediatric pelvis imaging necessity

Covered when ALL of the following are met

Pertinent clinical evaluation: A pertinent clinical evaluation (history, physical exam, appropriate laboratory studies, and basic imaging such as radiography or ultrasound) since onset or change in symptoms has been performed prior to advanced imaging; meaningful technological contact may substitute in some cases.

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Documented symptoms: The individual has documented active clinical signs or symptoms of pelvic disease; advanced imaging is not supported for asymptomatic screening unless otherwise specified by a guideline section.

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Ultrasound-first approach: Transabdominal ultrasound is the initial imaging for most pediatric pelvic conditions; transabdominal ultrasound is appropriate in all pediatric individuals and transvaginal ultrasound is conditional for sexually active/tampon-using consenting adolescents.

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Abnormal Uterine Bleeding (pediatric)

Covered when ALL of the following are met

Initial imaging: Transabdominal ultrasound is appropriate as the initial imaging study for pediatric individuals with abnormal uterine bleeding; transvaginal ultrasound is only appropriate for sexually active/tampon-using consenting individuals.

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Escalation to MRI: MRI pelvis without contrast or without and with contrast (CPT 72195 or CPT 72197) is medically necessary if transabdominal ultrasound is inconclusive.

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PID imaging criteria

Pelvic inflammatory disease (PID):

Initial evaluation: Transabdominal ultrasound is appropriate for all pediatric individuals suspected of PID; transvaginal ultrasound may be used for sexually active/tampon-using consenting individuals but is generally not appropriate for pre-pubescent or abused individuals.

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Advanced imaging escalation: If ultrasound is inconclusive, MRI pelvis without contrast (CPT 72195) or MRI pelvis without and with contrast (CPT 72197) is medically necessary; CT pelvis with contrast (CPT 72193) is medically necessary if MRI is not readily available.

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Amenorrhea imaging criteria

Amenorrhea (primary):

Initial evaluation: Pelvic ultrasound (CPT 76856 or CPT 76857) is indicated for females with primary amenorrhea (absence of menses by age 16) when associated with listed findings; transabdominal ultrasound is appropriate in all pediatric individuals and transvaginal ultrasound (CPT 76830) is appropriate for sexually active females for better evaluation of genitourinary anomalies.age 16 (definition of primary amenorrhea)

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When to use MRI: MRI pelvis (CPT 72195 or CPT 72197) and/or MRI abdomen (CPT 74181 or CPT 74183) are medically necessary for evaluation of congenital anomalies or for preoperative planning when indicated.

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Endometriosis imaging criteria

Endometriosis:

Initial imaging: Transabdominal ultrasound is appropriate in all pediatric individuals suspected of endometriosis; transvaginal ultrasound is appropriate only for sexually active/tampon-using consenting adolescents and generally not appropriate for pre-pubescent or never sexually active individuals.

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Adnexal mass imaging criteria

Suspected adnexal mass:

First-line imaging: Transabdominal ultrasound is the first-line study for suspected adnexal mass in pediatric individuals; transvaginal ultrasound is conditional for sexually active/tampon-using consenting individuals and generally not appropriate for pre-pubescent or never sexually active individuals.

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Age-based escalation: Adnexal masses with a solid component in individuals age ≥15 years should follow pediatric germ cell tumor imaging guidance for further evaluation.age >=15

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Pelvic pain and ovarian torsion imaging criteria

Pelvic pain / Ovarian torsion:

Acute evaluation: Transabdominal ultrasound (CPT 76856) with Doppler assessment (CPT 93975) is appropriate in all pediatric individuals with suspected ovarian torsion; transvaginal ultrasound with Doppler is conditional for sexually active/tampon-using consenting adolescents.

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Clinical note: Recognize that torsion can occur with a normal-appearing ovary and typically presents with acute lower abdominal pain, often with nausea or vomiting; imaging should be expedited to influence management.

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PCOS imaging criteria

Polycystic ovary syndrome (PCOS):

Imaging role: Transabdominal ultrasound (CPT 76856) is appropriate in pediatric individuals; transvaginal ultrasound (CPT 76830) is appropriate only for sexually active/tampon-using consenting adolescents. Imaging should not be used alone to diagnose PCOS; abnormal laboratory studies are required for diagnosis.

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Polycystic Ovary Syndrome (PEDPV-8.1)

Polycystic ovary syndrome imaging in pediatric individuals:

PCOS imaging specifics: Transabdominal ultrasound (CPT 76856) is appropriate for all pediatric individuals; transvaginal ultrasound (CPT 76830) only for sexually active adolescents or tampon users who consent; transvaginal ultrasound is generally not appropriate for pre-pubescent or never sexually active individuals. Diagnosis requires correlation with laboratory abnormalities and should not rely on ovarian morphology alone.

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Periurethral Cysts and Urethral Diverticula (PEDPV-9.1)

Imaging indications for periurethral cysts and urethral diverticula:

Periurethral cysts/urethral diverticula: Imaging indications in pediatric individuals are identical to adult indications; refer to the referenced Pelvis Imaging Guidelines for condition-specific imaging protocols.

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Fetal MRI (PEDPV-10.1)

Fetal MRI indications:

Fetal MRI indications and imaging protocols in pediatric individuals follow the same indications as in the referenced Pelvis Imaging Guidelines; consult the condition-specific section for details.

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Undescended Testis (PEDPV-11.1)

Suspected undescended testis:

Referral and initial imaging: Refer suspected undescended testis to a surgical subspecialist; scrotal ultrasound (CPT 76870) is medically necessary when the testis is not palpable and there is concern for retractile or inguinal testis.

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Advanced imaging after surgical consult: After surgical consultation, MRI abdomen (CPT 74183) and pelvis (CPT 72197) without and with contrast OR CT abdomen and pelvis with contrast (CPT 74177) are medically necessary if the consultant indicates imaging will change operative management; otherwise CT/MRI localization is generally not necessary.

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Scrotal Pathology (PEDPV-12.1)

Acute scrotal concerns:

Torsion workup: Scrotal ultrasound (CPT 76870) with Doppler (CPT 93975 or CPT 93976) is medically necessary for suspected testicular torsion.

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When MRI is appropriate: MRI pelvis without contrast (CPT 72195) or without and with contrast (CPT 72197) may be medically necessary if ultrasound is equivocal and no immediate surgical exploration is planned; scintigraphy is not medically necessary for acute scrotum evaluation.

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Penis-Soft Tissue Mass (PEDPV-13.1)

Penile soft tissue mass imaging:

Penile mass imaging: Imaging indications for penile soft tissue masses in pediatric individuals are the same as adult indications; consult the referenced Pelvis Imaging Guidelines for specifics.

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Incontinence (PEDPV-14.1)

Pediatric urinary incontinence:

No imaging for primary enuresis: No imaging is indicated for presumed primary enuresis; obtain a full medical history and urinalysis first.

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When imaging indicated: If structural causes (e.g., ureteral duplication, overactive bladder, dysfunctional voiding, or spinal abnormality) are suspected, imaging may be warranted; radionuclide urinary bladder residual study (CPT 78730) is medically necessary for suspected retention after a non-diagnostic ultrasound. MRI pelvis (CPT 72197) is medically necessary if ultrasound is inconclusive or a spinal abnormality is suspected; CT pelvis with contrast (CPT 72193) appropriate if MRI not available.

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Patent Urachus (PEDPV-15.1)

Patent urachus evaluation:

Initial evaluation: Ultrasound pelvis (CPT 76856) is medically necessary as the initial evaluation for suspected patent urachus; ultrasound has an accuracy greater than 90%.

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Advanced imaging if ultrasound insufficient: If ultrasound is inconclusive or insufficient for preoperative planning, ANY of MRI pelvis without contrast (CPT 72195), MRI pelvis without and with contrast (CPT 72197), or CT pelvis with contrast (CPT 72193) are medically necessary.

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Repeat imaging exceptions: Repeat imaging of asymptomatic individuals is not generally necessary but is medically necessary for new or worsening symptoms or for preoperative planning.

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Imaging coverage criteria for patent urachus

Covered when the following are met:

Initial ultrasound requirement: Ultrasound pelvis (CPT 76856) is medically necessary as the initial evaluation for suspected patent urachus.

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Advanced imaging options after inconclusive ultrasound: If ultrasound is inconclusive or insufficient for preoperative planning, ANY of MRI pelvis without contrast (CPT 72195), MRI pelvis without and with contrast (CPT 72197), or CT pelvis with contrast (CPT 72193) are medically necessary.

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Repeat imaging exceptions: Repeat imaging of asymptomatic individuals is not generally necessary, but is medically necessary for new or worsening symptoms or for preoperative planning.

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Studies, treatments, procedures, or devices that lack sufficient supporting evidence, have not demonstrated improved health outcomes, do not show clinical utility, or lack collective professional support are considered investigational/experimental and are not supported. Supporting evidence consists of peer‑reviewed literature and specialty society recommendations; requests for imaging that are part of research or inconsistent with established clinical standards (requested solely for data collection) are likewise not supported.

Pre-operative or pre-procedural imaging is not medically necessary when the proposed surgery or procedure itself is not medically necessary. Imaging intended solely to prepare for a procedure that is not indicated may be denied; once the procedure is approved or does not require prior authorization, appropriate pre-procedural imaging may be considered.

Do not bill CPT 76376 or CPT 76377 in conjunction with excluded modalities or contexts listed in the guideline (for example: CAD, MRA, CTA, nuclear medicine SPECT, PET/PET‑CT, stereotactic localization such as CPT 77011 or CPT 70486, mammography/breast MRI/US, CT colonography, cardiac CT/MRI, and similar excluded studies). Additionally, it is inappropriate to routinely bill a diagnostic procedure code together with an imaging guidance procedure code when the guidance code already includes the imaging necessary to perform the percutaneous procedure.

Whole‑body CT or so‑called "LifeScan" screening (CT Brain, Chest, Abdomen, and Pelvis) for asymptomatic individuals is not a covered benefit. Whole‑body MRI (WBMRI) is generally not supported due to lack of standardization and outcome evidence except in select, guideline‑specified indications (for example, defined cancer predisposition syndromes).

CPT 76380 (limited or follow‑up CT) is not medically necessary for treatment planning purposes and should not be used to cover additional slices or as a substitute for an appropriately reported diagnostic CT study.

CPT 76380 (limited/follow‑up CT) is explicitly identified as not medically necessary when used for treatment planning purposes and should not replace an appropriately coded diagnostic CT.

Use of advanced imaging (CT, MRI, PET, nuclear medicine) to screen asymptomatic individuals for pelvic disorders is not supported. Advanced whole‑body screening studies (e.g., whole‑body CT or unspecific WBMRI) lack evidence of benefit and may be denied unless a specific guideline exception applies.

Transvaginal ultrasound is generally not appropriate for pre‑pubescent individuals, victims of abuse, or those who have never been sexually active. In pediatric patients the guideline recommends transabdominal ultrasound as the initial modality; transvaginal ultrasound (CPT 76830) is permitted only for sexually active adolescents or those using tampons who provide consent.

Scintigraphy (nuclear medicine test) is not medically necessary for the evaluation of the acute scrotum. Doppler scrotal ultrasound is the recommended first‑line study for suspected testicular torsion and other acute scrotal pathology.

CT and MRI are generally not medically necessary to localize non‑palpable testes unless a surgical subspecialist documents that the imaging would alter the planned operative procedure. Surgical consultation should guide the need for advanced cross‑sectional imaging.

Routine repeat imaging in asymptomatic individuals is not generally necessary. Repeat studies should be performed only when there is documented evidence of progression, new or worsening symptoms, or when repeat imaging is required for preoperative planning and is expected to affect management.

Imaging requests that are inconsistent with established clinical standards or that are requested solely for data collection and not used in direct clinical management are not supported and may be denied. Requests must document a pertinent clinical evaluation and demonstrate that the imaging will impact patient care.

Repeat imaging without evidence of progression, recurrence, or likely impact on management is generally not medically necessary. Double‑contrast CT studies have few indications and should be justified; overutilization risks denial.

It is inappropriate to routinely bill a diagnostic procedure code in conjunction with an imaging guidance procedure code because guidance codes (CT, MR, ultrasound guidance) already include the necessary imaging to perform the percutaneous procedure.

Whole‑body MRI is generally not supported at this time due to lack of standardized technique and insufficient evidence of outcome benefit; when performed for accepted indications it should be reported using CPT 76498. Whole‑body CT screening is not covered for asymptomatic individuals.

CT should not be substituted for MRI solely to avoid sedation; CT may only replace MRI in that context when a specific guideline section explicitly lists CT as an appropriate alternative. The primary modality selection should be driven by the diagnostic question.

Appropriate Indications and Escalation Pathways

Pediatric pelvis-specific topics list

This section lists the pediatric pelvis-specific topics covered by these guidelines.

Topics included: Abnormal uterine bleeding; pelvic inflammatory disease (PID); amenorrhea; endometriosis; suspected adnexal mass; pelvic pain/ovarian torsion; polycystic ovary syndrome (PCOS); periurethral cysts and urethral diverticula; fetal MRI; undescended testis; scrotal pathology; penis soft-tissue mass; urinary incontinence; patent urachus; and related condition-specific guidance.

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Appropriate indications by modality

Select modality based on the diagnostic question; initial testing often follows an ultrasound-first approach.

Modality mapping: Ultrasound: initial evaluation for most pelvic soft tissue and gynecologic indications and real-time bedside assessment; CT: preferred for trauma, complex fractures, pulmonary disease, and detailed abdominal/pelvic viscera evaluation; MRI: preferred for superior soft tissue characterization and when CT/US are inconclusive or contraindicated.

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Ultrasound-first expectation: Transabdominal ultrasound is appropriate in all pediatric individuals and should precede advanced cross-sectional imaging unless otherwise specified by condition-specific guidance.

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When initial ultrasound is equivocal/indeterminate

When initial ultrasound is equivocal/indeterminate for specified pelvic conditions or for pre-operative planning where conventional imaging is insufficient, consider advanced imaging or 3D processing.

Escalation criteria: If transabdominal ultrasound is equivocal or indeterminate for conditions such as uterine intracavitary lesions, hydrosalpinx/peritoneal cysts, lost IUD, uterine anomalies, complex adnexal masses, or when preoperative planning requires enhanced anatomic depiction, advanced cross-sectional imaging (MRI or CT as appropriate) and/or 3D rendering (CPT 76376/76377) may be considered.

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Whole-Body MRI and CT appropriate use

Whole-body MRI and CT have limited, condition-specific roles.

Whole-body MRI use: Whole-body MRI is generally not supported except for select cancer predisposition syndromes, certain autoimmune indications, or specific oncologic staging/restaging scenarios; when performed, report as CPT 76498.

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Whole-body CT stance: Whole-body CT (LifeScan) for screening asymptomatic individuals is not a covered benefit and is not supported.

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Image guidance for percutaneous tumor ablation

Image guidance for percutaneous tumor ablation:

Ablation guidance: CT guidance (CPT 77013) and MR guidance (CPT 77022) are appropriate for percutaneous tumor ablation (77013 limited to non-bone ablation); CT guidance for bone ablation is CPT 20982. These codes include initial guidance, monitoring, and confirmation and are for percutaneous procedures only.one unit per encounter

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Lymphatic system mapping

Lymphatic system mapping is rarely used but medically necessary in specific circumstances.

Indications: Radiopharmaceutical localization imaging of the lymphatic system (CPT 78195) is medically necessary for lower extremity lymphedema with recent negative Doppler ultrasound, a history of Milroy's disease, or prior pelvic lymph node dissection.

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Abnormal uterine bleeding (pediatric)

Abnormal uterine bleeding (pediatric):

Initial imaging: Transabdominal ultrasound is the initial imaging in all pediatric individuals with abnormal uterine bleeding; transvaginal ultrasound only for sexually active/tampon-using consenting adolescents.

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MRI escalation: MRI pelvis (CPT 72195 or CPT 72197) is medically necessary if ultrasound is inconclusive.

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Pelvic inflammatory disease

Pelvic inflammatory disease:

Initial and escalation imaging: Transabdominal ultrasound is appropriate initially; transvaginal ultrasound is conditional for sexually active/tampon-using consenting adolescents; if ultrasound is inconclusive obtain MRI pelvis (CPT 72195 or 72197), or CT pelvis with contrast (CPT 72193) if MRI unavailable.

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Amenorrhea

Amenorrhea:

Primary amenorrhea evaluation: Pelvic ultrasound (CPT 76856/76857) is indicated for primary amenorrhea with appropriate clinical findings; transvaginal ultrasound (CPT 76830) is appropriate for sexually active adolescents; MRI pelvis/abdomen (CPT 72195/72197 and 74181/74183) is medically necessary for congenital anomalies or preoperative planning.age 16

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Suspected adnexal mass

Suspected adnexal mass:

Evaluation pathway: Ultrasound is the first-line study (transabdominal in all pediatric individuals; transvaginal only for sexually active/tampon-using consenting individuals). Solid components in individuals age ≥15 should follow pediatric germ cell tumor guidance.age >=15

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Pelvic pain / ovarian torsion

Pelvic pain / ovarian torsion:

First-line imaging: Transabdominal ultrasound with Doppler (CPT 76856 plus CPT 93975) is the recommended initial study in all pediatric individuals; transvaginal ultrasound with Doppler is conditional for sexually active/tampon-using consenting adolescents.

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Polycystic ovary syndrome

Polycystic ovary syndrome:

Imaging guidance: Transabdominal ultrasound (CPT 76856) is appropriate for pediatric individuals; transvaginal ultrasound (CPT 76830) is appropriate only for sexually active/tampon-using consenting adolescents; imaging must be correlated with laboratory abnormalities and not used alone for diagnosis.

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Polycystic Ovary Syndrome (PEDPV-8.1)

Polycystic Ovary Syndrome imaging:

PCOS imaging specifics: Transabdominal ultrasound appropriate in all pediatric individuals; transvaginal ultrasound only for sexually active adolescents or tampon users who consent; avoid TV ultrasound in pre-pubescent or never sexually active individuals; correlate imaging with labs.

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Undescended testis localization and pre-operative planning

Undescended testis localization and pre-operative planning:

Surgical referral and ultrasound: Refer to a surgical subspecialist; scrotal ultrasound (CPT 76870) is medically necessary when the testis is not palpable and there is concern for retractile or inguinal testis.

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Advanced imaging after consult: If the surgical consultant indicates advanced imaging will alter operative management, MRI abdomen (CPT 74183) and pelvis (CPT 72197) without and with contrast or CT abdomen and pelvis with contrast (CPT 74177) are medically necessary.

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Acute scrotal pain/torsion evaluation

Acute scrotal pain/torsion evaluation:

Initial imaging: Scrotal ultrasound (CPT 76870) with Doppler (CPT 93975 or 93976) is medically necessary for evaluation of acute scrotal pain and suspected torsion.

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Equivocal cases: If ultrasound is equivocal and no immediate surgical exploration is planned, MRI pelvis (CPT 72195 or CPT 72197) may be medically necessary; scintigraphy is not medically necessary for acute scrotum.

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Urinary incontinence evaluation

Urinary incontinence evaluation:

Primary enuresis: No imaging is required if primary enuresis is suspected; obtain medical history and urinalysis first.

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When imaging warranted: If structural causes are suspected (e.g., ureteral duplication, overactive bladder, dysfunctional voiding, or spinal abnormality), imaging may be warranted; radionuclide urinary bladder residual study (CPT 78730) is medically necessary after a recent non-diagnostic ultrasound; MRI pelvis (CPT 72197) is medically necessary if ultrasound is inconclusive or spinal abnormality suspected; CT pelvis with contrast (CPT 72193) appropriate if MRI unavailable.

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Patent urachus

Patent urachus:

Initial evaluation: Ultrasound pelvis (CPT 76856) is medically necessary as the initial evaluation for suspected patent urachus; ultrasound accuracy >90%.

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Advanced imaging for planning: If ultrasound is inconclusive or insufficient for preoperative planning, MRI pelvis without contrast (CPT 72195), MRI pelvis without and with contrast (CPT 72197), or CT pelvis with contrast (CPT 72193) are medically necessary.

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Suspected patent urachus; preoperative planning when ultrasound insufficient; new or worsening symptoms

Suspected patent urachus; preoperative planning when ultrasound insufficient; new or worsening symptoms:

Initial ultrasound mandatory: Suspected patent urachus requires an initial pelvic ultrasound (CPT 76856).

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Advanced imaging options: If ultrasound is inconclusive or insufficient for preoperative planning, any of MRI pelvis without contrast (CPT 72195), MRI pelvis without and with contrast (CPT 72197), or CT pelvis with contrast (CPT 72193) are medically necessary.

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Repeat imaging exceptions: Repeat imaging of asymptomatic individuals is not generally necessary; repeat imaging is medically necessary for new or worsening symptoms or for preoperative planning.

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Frequency limits — Repeat imaging of asymptomatic individuals is not generally necessary

Frequency limitRepeat imaging of asymptomatic individuals is not generally necessary.

Exception — new/worsening symptomsRepeat imaging is medically necessary for new or worsening symptoms.

Exception — preoperative planningRepeat imaging is medically necessary for preoperative planning when prior imaging is insufficient.

Any listed modality — Repeat imaging not generally necessary; allowed for new/worsening symptoms or preoperative planning

General ruleRepeat imaging of asymptomatic individuals is not generally necessary for any listed modality.

Allowed — symptom changeRepeat imaging is allowed if there are new or worsening symptoms that could affect management.

Allowed — preoperativeRepeat imaging is allowed when required for preoperative planning because prior studies are inconclusive or insufficient.

Procedure Codes and Coding Guidance

Experimental / Investigational CPTCPTExperimental

C9791

MRI utilizing Xenon Xe 129

3D Rendering CPT CodesCPT

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), 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
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 ablation-related CPT codesCPT

77013	CT guidance for percutaneous tumor ablation (not for bone ablation); includes initial guidance, monitoring, and confirmation; one unit per encounter
77022	MR guidance for percutaneous tumor ablation; includes initial guidance, monitoring, and confirmation; one unit per encounter
20982	Includes CT guidance for bone tumor ablations
77012	Other CT guidance code (context: different modality guidance)
77021	Other MR guidance code (context: different modality guidance)
76942	Ultrasound guidance
77002	Fluoroscopy guidance range (77002-77003 referenced)

Unlisted procedure CPT codesCPT

76497	Unlisted CT procedure
76498	Unlisted MR procedure (including current reportable code for whole-body MRI)
78999	Unlisted diagnostic nuclear medicine procedure

Limited CT codeCPT

76380

Limited or follow-up CT scan (limited CT); not medically necessary for treatment planning

SPECT/CT and nuclear imaging codesCPT

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

PET/MRI code combinationCPT

78813	PET Whole-Body (used in PET/MRI code combination)
76498	Unlisted MR procedure (used in PET/MRI code combination)

HCPCS examples and guidanceHCPCS

C8931	Example HCPCS - MRA with dye, Spinal Canal (not exhaustive)
S8042	Non-specific HCPCS (MRI, low-field) — should be redirected to appropriate CPT when possible

Interpretation codesCPT

76140

Secondary interpretation of images obtained elsewhere

Primary MRI and CT CPT 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

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CTA, PET, Nuclear Medicine CPT 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 Imaging; limited area
78812	PET Imaging: skull base to mid-thigh
78813	PET Imaging: whole body
78814	PET with concurrently acquired CT; limited area
78815	PET with concurrently acquired CT; skull base to mid-thigh
78816	PET with concurrently acquired CT; whole body

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Ultrasound and Duplex CPT 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 and/or retroperitoneal organs; complete
93976	Duplex scan ... limited study
93978	Duplex scan of aorta, IVC, iliac vasculature; complete
93979	Duplex scan ... limited
93980	Duplex penile vessels; complete

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Covered ultrasound CPT codesCPTCovered

76856	Transabdominal pelvic ultrasound (single or first study)
76857	Transabdominal pelvic ultrasound (repeat or limited/additional views)

Conditional transvaginal ultrasoundCPTCovered

76830

Transvaginal pelvic ultrasound

MRI pelvis codesCPTCovered

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

CT pelvis codesCPTCovered

72193

CT pelvis with contrast

Doppler ultrasound codeCPTCovered

93975

Doppler assessment (used with pelvic ultrasound)

PCOS - Ultrasound codesCPTCovered

76856	Transabdominal ultrasound
76830	Transvaginal ultrasound

Scrotal/Undescended Testis Ultrasound and DopplerCPTCovered

76870	Scrotal ultrasound
93975	Doppler study (arterial/venous) - context: scrotal Doppler
93976	Doppler study (arterial/venous) - alternate code

Advanced cross-sectional imaging (MRI/CT)CPTCovered

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

Nuclear Medicine - bladder residual studyCPTCovered

78730

Radiopharmaceutical urinary bladder residual study

Covered CPT Codes (initial evaluation)CPTCovered

76856

Ultrasound pelvis

Covered CPT Codes (if ultrasound inconclusive or insufficient)CPTCovered

72195	MRI Pelvis without contrast
72197	MRI Pelvis without and with contrast

Covered CPT Codes (alternative advanced imaging)CPTCovered

72193

CT Pelvis with contrast

Anesthesia age threshold — MRI anesthesia usually required for almost all infants and young children <7 years

Age thresholdMRI anesthesia is usually required for almost all infants (except neonates) and young children younger than 7 years.

Older childrenAnesthesia may also be required for older children with developmental delays or lack of cooperation.

Anesthesia planningWhen possible, obtain all indicated MRI studies during a single anesthesia session to minimize exposure.

Prior Authorization, Documentation, and Ordering Guidance

Prior Authorization

Prior authorization / medical necessity review

Prior authorization and medical necessity: Advanced pelvic imaging and select procedures will be reviewed under Ohio rules and may require prior authorization when medical necessity is not evident from submitted records. Submit adequate clinical information including recent history, physical exam, relevant laboratory results, and any prior imaging studies since symptom onset or change. Scheduled, guideline-supported follow-up imaging may not require a new clinical evaluation if noted in the condition-specific section.

Provide detailed HPI, exam findings, and relevant labs.
Include dates and reports of prior imaging studies.
When requesting advanced imaging after surveillance, indicate guideline-supported schedule.

Prior Authorization

Prior authorization / justification

Justification for advanced imaging requests: When requesting MRI, CT, PET/MRI, or other advanced modalities, include a recent clinical evaluation (since onset or change in symptoms) and any prior imaging that demonstrates why ultrasound or less invasive testing is insufficient. If the requested imaging is for preoperative planning or scheduled surveillance, document the rationale and prior findings that necessitate escalation.

Document why ultrasound (CPT 76856/76857) was inconclusive or insufficient.
Include operative or surgical consult notes when imaging is for preoperative planning.
Specify how the imaging result will change management.

Documentation Required

Prior authorization for 3D rendering

3D rendering (CPT 76376/76377): Document the physician’s concurrent supervision or active participation in the post‑processing and reconstruction. Prior authorization may be required for these codes even when the underlying study (e.g., CT, MRI, or ultrasound) did not require prior authorization.

Indicate whether an independent workstation was used (76377) or not (76376).
Do not report 3D rendering for 2D reformatting — 2D reformatting is included in base cross‑sectional codes.

Prior Authorization

PET/MRI reporting and medical necessity

PET/MRI considerations: PET/MRI is generally not supported except in select circumstances. It is medically necessary only when the individual meets condition‑specific PET/MRI criteria OR when ALL of the following are true: the individual meets PET/CT guideline criteria, PET/CT is not available at the treating institution, and the provider requests PET/MRI instead of PET/CT. Use CPT 78813 + 76498 to report PET/MRI; include clinical justification and documentation that PET/CT was unavailable.

If requesting PET/MRI, document why PET/CT cannot be performed at the treating institution.
When appropriate, submit diagnostic MRI codes concurrently if clinically indicated.

Billing Rule

Procedure codes requiring authorization

Procedure codes requiring authorization and ultrasound-first approach: Many pelvis imaging codes (see procedure list) may require prior authorization when clinical documentation is insufficient. Ultrasound (transabdominal CPT 76856 or limited CPT 76857; transvaginal CPT 76830 when appropriate) is expected as the initial imaging in most pelvic conditions; advanced imaging (MRI/CT) should only be ordered if ultrasound is inconclusive or insufficient for management or preoperative planning.

List of commonly affected codes: MRI Pelvis 72195/72197; CT Pelvis 72193; Ultrasound pelvic complete 76856; limited 76857; transvaginal 76830; scrotal ultrasound 76870.
Advanced imaging (MRI 72195/72197 or CT 72193) is medically necessary only after inconclusive ultrasound or when ultrasound cannot answer the clinical question.

Step Therapy

Advanced pelvic cross‑sectional imaging and ultrasound‑first approach

Stepwise imaging and documentation expectations: Follow an ultrasound‑first, stepwise pathway—transabdominal ultrasound first (CPT 76856/76857), transvaginal ultrasound (CPT 76830) only when appropriate/consented, then escalate to MRI or CT if ultrasound is inconclusive or insufficient for surgical planning. Always document initial ultrasound findings and include rationale when requesting advanced imaging.

Include the initial ultrasound report (CPT 76856) and clearly state why it is inconclusive or insufficient.
If requesting MRI/CT after ultrasound, attach prior ultrasound images/reports for comparison.
Document patient consent or appropriateness for transvaginal ultrasound in pediatric or special populations.

Billing Rule

If an outside exam is interpreted secondarily

Outside exam interpretation and coding: It is inappropriate to use diagnostic imaging codes to report interpretation of an exam performed elsewhere. When a secondary interpretation of an outside study is performed, report CPT 76140. If the outside exam is used for comparison, include the prior study in the current diagnostic interpretation documentation rather than billing a separate diagnostic code for the old study.

For secondary reads of external exams, bill CPT 76140.
Do not report diagnostic imaging codes for interpretation-only of outside exams.

Denial Risk

Whole‑body CT/MRI screening for asymptomatic individuals

Whole‑body CT/MRI screening and overutilization risk: Whole‑body CT screening (LifeScan) for asymptomatic individuals is not a covered benefit and will be denied. Whole‑body MRI is generally not supported except for select cancer predisposition syndromes or specific oncologic indications; document condition‑specific justification if requested.

Whole‑body CT screening (CT Brain/Chest/Abdomen/Pelvis) for asymptomatic screening is not covered.
WBMRI is reportable only with CPT 76498 and is generally not supported except where condition‑specific guidelines allow.

Definitions and Key Terms

Pertinent clinical evaluation — recent history, physical exam, labs, prior imaging

HistoryPertinent recent clinical history since onset or change in symptoms should be submitted (detailed history).

Physical examDocument relevant physical examination findings associated with the pelvic complaint.

Laboratory studiesInclude appropriate laboratory studies (e.g., pregnancy test, FSH/LH when relevant) to support imaging indication.

Prior imagingProvide prior imaging studies and reports to demonstrate inconclusive findings or to justify escalation to advanced imaging.

Ultrasound — diagnostic ultrasound definition/context

DefinitionDiagnostic ultrasound uses high-frequency sound waves to evaluate soft tissue structures and vascular structures utilizing gray scale and Doppler techniques.

CapabilitiesProvides dynamic real-time imaging at the bedside and is operator-dependent.

Typical usesInitial evaluation for obstetric/gynecologic imaging, soft tissue and visceral imaging, vascular studies, and procedural guidance when feasible.

CT — computed tomography definition and contrast options

DefinitionComputed tomography (CT) uses ionizing radiation to create cross-sectional and volumetric images; it may be performed without, with, or without and with IV contrast depending on indication.

Contrast considerationsCT with iodinated contrast improves vascular and soft tissue resolution; CT without contrast is appropriate when contrast contraindicated (e.g., renal insufficiency, allergies).

Use casesPreferred for trauma, rapid imaging, evaluation of bony structures and certain abdominal/pelvic viscera; should not be used to replace MRI solely to avoid sedation unless guideline supports it.

MRI — magnetic resonance imaging definition and contrast options

DefinitionMagnetic resonance imaging (MRI) provides superior soft tissue characterization without ionizing radiation and may be performed without, with, or without and with gadolinium-based contrast agents.

Contrast guidanceGadolinium-based contrast agents (GBCAs) are used to characterize perfusion/vascularity; limit GBCA use to situations where additional information is necessary and assess cumulative exposure, especially in pediatrics.

Practical considerationsMRI is time-consuming and often requires anesthesia in young children; plan studies to minimize repeat anesthesia exposure by combining regions when indicated.

Concurrent supervision (3D rendering) — definition of active physician participation

DefinitionConcurrent supervision for 3D rendering requires active physician participation and monitoring of the reconstruction process, including design of the anatomic region, determination of tissues/structures to display, selection of images/cine loops to archive, and monitoring/adjustment of the 3D work product.

DocumentationPhysician supervision/participation should be documented per ACR recommendations when billing CPT 76376/76377.

Workstation distinctionCPT 76376 is for rendering not requiring an independent workstation; CPT 76377 requires independent workstation post-processing.

Guidance codes (CPT 77013, 77022) — definition and included services

Included servicesCPT 77013 (CT) and CPT 77022 (MR) include initial direction of a needle electrode to the tumor, monitoring for repositioning, multiple ablations as needed, and confirmation of coagulative necrosis.

Procedure scopeCPT 77013 is limited to non-bone ablation; CPT 20982 covers CT guidance for bone ablations.

Reporting ruleOnly one unit of these guidance codes should be reported per individual encounter and they apply to percutaneous procedures (not open/excisional surgeries).

Unlisted CT/MR (CPT 76497/76498) — usage guidance when site-specific codes absent

When to useUse CPT 76497 (unlisted CT) or CPT 76498 (unlisted MR) when no appropriate anatomic site-specific CT or MR code exists for the performed diagnostic or interventional study.

Category III preferenceIf a Category III code describes the procedure, report that instead of an unlisted code when available.

Whole-body MRI reportingWhole-body MRI is reportable using CPT 76498 per guidance on WBMRI coding considerations.

Individuals age 18 years or younger — pediatric population definition

Pediatric definitionIndividuals age 18 years or younger are considered pediatric for the purposes of these guidelines and should be imaged per the Pediatric Pelvis Imaging Guidelines.

Transition to adult guidelinesIndividuals >19 years should follow the General Pelvis Imaging Guidelines unless directed otherwise by a specific section.

Age-specific differencesSome conditions differ in pediatric versus adult populations and may require modified management or imaging approaches.

Gadolinium use guidance — limit GBCA and coordinate exposures

Limit GBCA useLimit gadolinium-based contrast agent (GBCA) use to situations where contrast provides necessary additional information.

Cumulative exposureConsider cumulative GBCA exposure and plan combined imaging during a single anesthesia session when possible to avoid repeat exposures.

Safety considerationsGadolinium has risks in renal failure and is relatively contraindicated in pregnancy; assess renal function (GFR) before administration.

Abnormal vaginal bleeding (pediatric) — definition

DefinitionAbnormal vaginal bleeding in pediatric individuals is vaginal bleeding occurring after the neonatal period but before menarche and requires evaluation.

Common causesBefore menarche, causes may include foreign bodies, infections, precocious puberty, and estrogen exposure; after menarche consider pregnancy and ovulatory dysfunction.

Clinical actionTransabdominal ultrasound is the initial imaging modality for evaluation.

Ovarian torsion (pediatric) — definition and presentation

DefinitionOvarian torsion involves twisting of the ovary and fallopian tube and commonly presents with acute onset lower abdominal pain, often with nausea or vomiting.

Pediatric presentationTorsion in children is often spontaneous and may involve a normal ovary more commonly than a mass-related torsion.

Initial imagingTransabdominal ultrasound with Doppler is appropriate for all pediatric individuals with suspected torsion.

urachus — definition

DefinitionThe urachus is an embryologic tubular connection between the fetal bladder and the umbilical cord that typically obliterates after birth.

If patentWhen patent, the urachus may form a communication between the bladder and the umbilicus (complete or partial).

Clinical relevanceUltrasound is highly accurate (>90%) for evaluating suspected patent urachus.

Urachus / patent urachus — expanded definition

Expanded definitionA patent urachus is a persistent embryologic tubular connection between the bladder and umbilicus that can be complete or partial, and may require imaging for diagnosis and preoperative planning.

Initial evaluationUltrasound pelvis (CPT 76856) is medically necessary as the initial evaluation due to >90% accuracy.

Advanced imagingIf ultrasound is inconclusive or insufficient for preoperative planning, MRI pelvis (72195 or 72197) or CT pelvis with contrast (72193) are medically necessary options.

OpenPayer

Pediatric Pelvis Imaging Guidelines (For Ohio Only)

Coverage Criteria and Condition-Specific Indications

Appropriate Indications and Escalation Pathways

Procedure Codes and Coding Guidance

Prior Authorization, Documentation, and Ordering Guidance

Prior Authorization Notes

Contrast Use and Reporting Guidelines

Services Not Covered / Exclusions

Definitions and Key Terms

Frequency and Repeat Imaging Limits

Background and Evidence Summary