PV-1: General Policies

PV-1.1: General Policies - Overview

This General Policy section provides an overview of the basic criteria for which pelvis imaging may be medically necessary. Details regarding specific conditions or clinical presentations and the associated criteria for which imaging is medically necessary are described in subsequent sections.

PV-1.1: General Guidelines – Overview

For this condition imaging is medically necessary based on the following criteria:

† A current clinical evaluation (within 60 days) is required before advanced imaging can be considered. The clinical evaluation may include a relevant history and physical examination, appropriate laboratory studies, and non-advanced imaging modalities such as plain x-ray or Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or Transvaginal ultrasound (CPT^® 76830).

® The clinical evaluation may also include a gynecological and/or urological exam with appropriate laboratory studies such as blood count, tumor markers and endocrine evaluations.
® Other meaningful contact (telephone call, electronic mail or messaging) by an established member can substitute for a face-to-face clinical evaluation.

† Pregnant women should be evaluated with ultrasound or MRI without contrast to avoid radiation exposure. In carefully selected clinical circumstances, evaluation with CT may be considered with careful attention to technique and radiation protection as deemed clinically appropriate.

Ultrasound

† Transvaginal ultrasound is the recommended modality for imaging; no alternative modality has demonstrated sufficient superiority to justify routine use, and Transvaginal ultrasound (TV) (CPT^® 76830) is the optimal study to evaluate adult female pelvic pathology.

† Pelvic ultrasound (complete CPT^® 76856, or limited CPT^® 76857) can be performed if it is a complementary study to the TV ultrasound. It may substitute for TV in pediatric members or non-sexually active females.

† CPT^® 76942 is used to report ultrasound imaging guidance for needle placement during biopsy, aspiration, and other percutaneous procedures.

Soft Tissue Ultrasound

† Pelvic wall, buttocks, penis and perineum - CPT^® 76857

† Groin - CPT^® 76882

Scrotal Ultrasound

† See

® PV-17: Impotence/Erectile Dysfunction
® PV-18: Penis-Soft Tissue Mass

Other Ultrasound

† CPT^® 93975 Duplex scan (complete) of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study.

† CPT^® 93976 Duplex scan (limited) of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study.

† CPT^® 93975 and CPT^® 93976 should not be reported together during the same session.

† 3D Rendering (CPT^® 76376 or CPT^® 76377)

® CPT^® 76377 (3D rendering requiring image post-processing on an independent work station) or CPT^® 76376 (3D rendering not requiring image post-processing on an independent workstation) can be considered in the following clinical scenarios:
¡ Uterine intra-cavitary lesion when initial ultrasound is equivocal (See PV-2.1: Abnormal Uterine Bleeding (AUB) and PV-12.1: Leiomyomata)
¡ Hydrosalpinges or peritoneal cysts when initial ultrasound is equivocal (See PV-5.3: Complex Adnexal Masses)
¡ Lost IUD (inability to feel or see IUD string) with initial ultrasound (See PV-10.1: Intrauterine Device)
¡ Uterine anomalies with initial ultrasound (See PV-14.1: Uterine Anomalies)
¡ Infertility (See PV-9.1: Infertility Evaluation, Female)

† CT Pelvis with contrast is a possible modality unless there is a contrast allergy or CT without contrast to look for a calculus in the distal ureter or bladder.

® CT is not generally warranted for evaluating pelvic anatomy because it is limited due to soft tissue contrast resolution.

† Can be used as a more targeted study or for members allergic to iodinated contrast.

® MRI Pelvis without contrast (CPT^® 72195)
® MRI Pelvis without and with contrast (CPT^® 72197)
® MRI Pelvis with contrast only (CPT^® 72196) is rarely performed.

1. Practice Bulletin No. 174. The Evaluation and Management of Adnexal Masses. Obstetrics & Gynecology. 2016;128(5):1193-1195. doi:10.1097/aog.0000000000001763.
2. Lakshmy S, Rose N, Ramachandran M. Role of three dimensional ultrasound in uterine anomalies - 3D assessment of cervix in septate uteri. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2016:3563-3567. doi:10.18203/2320-1770.ijrcog20163445.
3. Bocca SM, Oehninger S, Stadtmauer L, et al. A Study of the Cost, Accuracy, and Benefits of 3-Dimensional Sonography Compared With Hysterosalpingography in Women With Uterine Abnormalities. Journal of Ultrasound in Medicine. 2012;31(1):81-85. doi:10.7863/jum.2012.31.1.81.
4. Benacerraf BR, Abuhamad AZ, Bromley B, et al. Consider ultrasound first for imaging the female pelvis. American Journal of Obstetrics and Gynecology. 2015;212(4):450-455. doi:10.1016/j.ajog.2015.02.015.
5. Bocca SM, Abuhamad AZ. Use of 3-Dimensional Sonography to Assess Uterine Anomalies. Journal of Ultrasound in Medicine. 2013;32(1):1-6. doi:10.7863/jum.2013.32.1.1.
6. Turkgeldi E, Urman B, Ata B. Role of Three-Dimensional Ultrasound in Gynecology. Journal of Obstetrics and Gynaecology of India. 2014;65(3):146-154. doi:10.1007/s13224-014-0635-z.
7. Graupera B, Pascual MA, Hereter L, et al. Accuracy of three-dimensional ultrasound compared with magnetic resonance imaging in diagnosis of Müllerian duct anomalies using ESHRE-ESGE consensus on the classification of congenital anomalies of the female genital tract. Ultrasound in Obstetrics & Gynecology. 2015;46(5):616-622. doi:10.1002/uog.14825.
8. Sakhel K, Benson CB, Platt LD, Goldstein SR, Benacerraf BR. Begin With the Basics. Journal of Ultrasound in Medicine. 2013;32(3):381-388. doi:10.7863/jum.2013.32.3.381.
9. Makris N, Kalmantis K, Skartados N, Papadimitriou A, Mantzaris G, Antsaklis A. Three-dimensional hysterosonography versus hysteroscopy for the detection of intracavitary uterine abnormalities. International Journal of Gynecology & Obstetrics. 2007;97(1):6-9. doi:10.1016/j.ijgo.2006.10.012.

PV-2.1: Abnormal Uterine Bleeding (AUB)

For this condition imaging is medically necessary based on the following criteria:

† Initial evaluation includes any of the following:

® Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or Transvaginal ultrasound (CPT^® 76830), D&C and/or endometrial biopsy

† If ultrasound is equivocal for intracavitary lesion, Duplex (Doppler) scan (CPT^® 93975 complete; CPT^® 93976 limited) may be approved as an add-on to TV ultrasound (CPT^® 76830).

† If ultrasound is equivocal for an intracavitary lesion, saline infusion sonohysterography (CPT^® 76831) may be indicated.

† CT is not generally warranted for evaluating AUB since uterine anatomy is limited due to soft tissue contrast resolution.

® An abnormal endometrium found incidentally on CT should be referred for TV ultrasound for further evaluation.

PV-3.1: Amenorrhea

For this condition imaging is medically necessary based on the following criteria:

† If a pregnancy test is negative:

® Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830).

† MRI Pelvis without contrast (CPT^® 72195) or without and with contrast (CPT^® 72197) can be performed if ultrasound is indeterminate or equivocal for Asherman’s Syndrome, Polycystic Ovary Syndrome, or Androgen Secreting Ovarian Tumor.

† Suspicion for hormonally active adrenal tumor should be evaluated by criteria in AB-16: Adrenal Cortical Lesions in the Abdomen Imaging Guidelines.

† Members with absent uterus or a foreshortened vagina should have karyotype evaluation. (See PV-14.1: Uterine Anomalies)

† MRI Brain (pituitary protocol) without and with contrast (CPT^® 70553) can be performed if:

® Estradiol is low with finding of inappropriately normal or low gonadotropins
® Prolactin (PRL) level is elevated above normal
® See HD-19: Pituitary in the Head Imaging Guidelines.

PV-3.2: Amenorrhea - Delayed Puberty

For this condition imaging is medically necessary based on the following criteria:

† Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830),

† Hysterosalpingogram (CPT^® 74740), sonohysterosalpingography (CPT^® 76831), and/or hysteroscopy can be performed if ultrasound is indeterminate.

† MRI Brain (pituitary protocol) without and with contrast (CPT^® 70553) can be performed if:

® Estradiol is low with finding of inappropriately normal or low gonadotropins
® Prolactin (PRL) level is elevated
® See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-19: Pituitary in the Head Imaging Guidelines.

Many medications are known to often result in hyperprolactinemia. More common offenders include antipsychotics (first generation and second generation e.g. Haloperidol and Risperidone, respectively), antidepressants (cyclic, SSRIs, e.g. Amitriptyline, Citalopram), anti-emetics and other gastrointestinal agents (such as Metoclopramide and Prochloroperazine), opioid analgesics (methadone, morphine), and antihypertensives (Verapamil, Methyldopa).

References
1. Hoffman BL, Schorge JO, Schaffer JI, et al. Chapter 16. Amenorrhea. In: Hoffman BL, Schorge JO, Schaffer JI, et al, eds. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
2. The American College of Obstetricians and Gynecologists (ACOG). Guidelines for Women’s Health Care. A Resource Manual. 4th edition, 2014.
3. Klein DA and Poth MA. Amenorrhea: an approach to diagnosis and management. Am Fam Physician. 2013 Jun 1;87(11):781-788.
4. Melmed S, Casanueva FF, Hoffman AR, et al. Diagnosis and Treatment of Hyperprolactinemia: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2011;96(2):273-288. doi:10.1210/jc.2010-1692.
5. Committee Opinion No. 605. Primary Ovarian Insufficiency in Adolescents and Young Women. Obstetrics & Gynecology. 2014;124(1):193-197. doi:10.1097/01.aog.0000451757.51964.98. (July 2014, Reaffirmed 2018).
6. Female athlete triad. Committee Opinion No. 702. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e160–7. doi:10.1097/aog.0000000000002113.
7. Polycystic ovary syndrome. ACOG Practice Bulletin No. 194. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e157–71. doi:10.1097/aog.0000000000002656.



PV-4: Adenomyosis

PV-4.1: Adenomyosis

PV-4.1: Adenomyosis

PV-4.1: Adenomyosis

For this condition imaging is medically necessary based on the following criteria:

† TV ultrasound (CPT^® 76830) and/or Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) is the diagnostic procedure of choice for the initial evaluation of suspected adenomyosis. Doppler ultrasound (CPT^® 93975 or CPT^® 93976) can be added if requested.

† MRI Pelvis without contrast (CPT^® 72195) or MRI Pelvis without and with contrast (CPT^® 72197) is considered a second-line imaging option after transvaginal ultrasound if:

® Inconclusive ultrasound and the member has failed several months (3 months) of hormone suppression

Reference
1. Practice Bulletin No. 128. Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. Obstet Gynecol. 2012 Jul;120(1):197-206. doi:10.1097/aog.0b013e318262e320. (July 2012, Reaffirmed 2016).
2. Bazot M, Daraï E. Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertility and Sterility. 2018;109(3):389-397. doi:10.1016/j.fertnstert.2018.01.024.

PV-5: Adnexal Mass/Ovarian Cysts

PV-5.1: Suspected Adnexal Mass – Initial Evaluation in All Women

PV-5.2: Simple Cysts

PV-5.3: Complex Adnexal Masses

PV-5.4: Screening for Ovarian Cancer/Suspected Ovary Cancer

PV-5.1: Suspected Adnexal Mass – Initial Evaluation in All Women

For this condition imaging is medically necessary based on the following criteria:

† A potential mass is found on exam and/or other imaging

† Transvaginal (TV) ultrasound imaging (CPT^® 76830) is the initial study of choice.

® Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) can be performed if requested as a complimentary study to the TV ultrasound.
® Once confirmed, Color Doppler ultrasonography (CPT 93975) may be useful to evaluate the vascular characteristics of adnexal masses.

® If the mass is unrelated to female pelvic anatomy, See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-13: Abdominal Mass in the Abdomen Imaging Guidelines

Practice Notes

† “Indeterminate” is commonly used to describe a complex adnexal mass. A complex mass should describe whether or not there are septations, mural projections, papillary excrescences, and comment of vascularity, instead of just describing the mass as ”indeterminate”.

† “Equivocal” is another commonly used term. Further information should indicate what the mass or lesion is equivocal for, for instance, ectopic pregnancy, functional cysts, tuboovarian abscess, hydrosalpinx, dermoid, endometrioma, hemorrhagic cyst or pedunculated fibroids.

† Consultation with or referral to a gynecologic oncologist is recommended for women with an adnexal mass who meet one or more of the following criteria:⁷

® Postmenopausal with elevated CA-125 level ultrasound findings suggestive of malignancy, ascites, a modular or fixed pelvic mass, or evidence of abdominal or distant metastasis.⁷
® Premenopausal with very elevated CA-125 level, ultrasound findings suggestive of malignancy, ascites, a nodular or fixed pelvic mass, or evidence of abdominal or distant metastasis.⁷
® Premenopausal or postmenopausal with an elevated score on a formal risk assessment test such as the multivariate index assay, risk of malignancy index, or the Risk of Ovarian Malignancy Algorithm or one of the ultrasound-based scoring systems from the International Ovarian Tumor Analysis group.⁷

® Simple cysts are smooth walled and clear without debris. Simple cysts up to 10 cm in diameter as measured by ultrasound are almost universally benign and may safely be followed with ultrasound, without intervention, even in postmenopausal women and pediatric members with normal tumor markers.
® Complex cysts can have solid areas or excrescences, and/or debris in them, greater than 3mm irregular septations, mural nodules with Doppler-detected blood flow, and/or free abdominal/pelvic fluid.

® The adnexa include the ovaries, Fallopian tubes, and ligaments that hold the uterus in place.
® CA-125 is a tumor marker that is useful for the evaluation of adnexal mass:
¡ Elevation occurs with both malignant (epithelial cancer) and benign entities (leiomyoma, endometriosis, PID, inflammatory disease such as lupus, and inflammatory bowel disease).
¡ Increase in the markers over time occurs with malignancy only
¡ Obtain CA-125 in all post-menopausal members with simple cyst >10cm.
¡ Consider tumor markers in members with an abnormal ultrasound that is not a simple cyst
® Other markers include Beta hCG, LDH, and AFP (germ cell tumors) and Inhibin A and B (granulosa cell tumor).

For this condition imaging is medically necessary based on the following criteria:

† For simple or thin walled cystic mass, follicular cyst (ovarian), tubular cystic mass (fallopian tube) on initial TV ultrasound (CPT^® 76830):

® Repeat TV ultrasound (CPT^® 76830) and/or Pelvic ultrasound (CPT^® 76857 or CPT^® 76856)
¡ According to the below schedule if ≤10 cm
¡ Cysts >10cm have not been studied and the current recommendation is to consider surgical intervention.

For this condition imaging is medically necessary based on the following criteria:

Condition	Pre-Menopausal	Post-Menopausal
Hemorrhagic cyst	† If initial imaging confirms hemorrhagic cyst, follow up with pelvic ultrasound (CPT® 76856 or CPT® 76857 and/or [transvaginal] CPT® 76830) in 8-12 weeks in the proliferative phase, if possible. Duplex (Doppler) scan (CPT® 93975 complete; CPT® 93976 limited) may be approved as an add-on to TV US (CPT® 76830). ® If follow-up imaging confirms a hemorrhagic cyst that has not completely resolved, a repeat ultrasound (CPT® 76856 or CPT® 76857 and/or CPT® 76830 [transvaginal]) can be performed in 6 months (sooner if signs or symptoms persist or if new symptoms occur). † A one time MRI Pelvis without and with contrast (CPT® 72197) maybe approved for Hemorrhagic cyst ≥10cm	N/A
Endometriomas	† If initial imaging confirms an Endometrioma, follow-up ultrasound (CPT® 76856 or CPT® 76857 and/or CPT® 76830 [transvaginal]) can be performed at 8 to 12 weeks in the proliferative phase, if possible; duplex (Doppler) scan (CPT® 93975 complete; CPT® 93976 limited) may be approved as an add-on to TV US (CPT® 76830). ® If ultrasound equivocal for Endometriomas, Pelvic MRI without and with contrast (CPT® 72197) † A one time MRI Pelvis without and with contrast (CPT® 72197) maybe approved for Endometriomas ≥10cm
Dermoids	† If initial imaging confirms a dermoid, follow-up ultrasound (CPT® 76856 or CPT® 76857 and/or CPT® 76830 [transvaginal]) can be performed at 6 to 12 months; duplex (Doppler) scan (CPT® 93975 complete; CPT® 93976 limited) may be approved as an add-on to TV US (CPT® 76830). ® If surgical resection is not performed, then follow-up pelvic ultrasound (CPT® 76856 or CPT® 76857 and/or CPT® 76830 [transvaginal]) can be obtained every 6 to 12 months. † If initial ultrasound imaging (CPT® 76857 or CPT® 76856 and/or transvaginal CPT® 76830) equivocal for Dermoids, the diagnosis can be confirmed by CT Pelvis (contrast as requested) or MRI Pelvis without contrast (CPT® 72195) or MRI Pelvis without and with contrast (CPT® 72197). ® If surgical resection is not performed, then follow-up pelvic ultrasound (CPT® 76856 or CPT® 76857 and/or CPT® 76830 [transvaginal]) can be obtained every 6 to 12 months. † A one time MRI Pelvis without and with contrast (CPT® 72197) maybe approved for Dermoids ≥10cm	† If initial imaging confirms a dermoid, follow-up ultrasound (CPT® 76856 or CPT® 76857 and/or CPT® 76830 [transvaginal]) can be performed at 6 to 12 months; duplex (Doppler) scan (CPT® 93975 complete; CPT® 93976 limited) may be approved as an add-on to TV US (CPT® 76830). ® If surgical resection is not performed, then follow-up pelvic ultrasound (CPT® 76856 or CPT® 76857 and/or CPT® 76830 [transvaginal]) can be obtained every 6 to 12 months. † If initial ultrasound imaging (CPT® 76857 or CPT® 76856 and/or transvaginal CPT® 76830) equivocal for dermoids, the diagnosis can be confirmed by CT Pelvis (contrast as requested) or MRI Pelvis without contrast (CPT® 72195) or MRI Pelvis without and with contrast (CPT® 72197). ® If surgical resection is not performed, then follow-up pelvic ultrasound (CPT® 76856 or CPT® 76857 and/or CPT® 76830 [transvaginal]) can be obtained every 6 to 12 months † A one time MRI Pelvis without and with contrast (CPT® 72197) maybe approved for Dermoids ≥10cm
Hydrosalpinges (Hydrosalpinx) or Peritoneal cysts	† If initial imaging confirms hydrosalpinx or peritoneal cysts, advanced imaging is rarely indicated in these clinical scenarios. Send for physician review. † If initial ultrasound imaging (CPT® 76857 or CPT® 76856 and/or transvaginal CPT® 76830) equivocal for Hydrosalpinges, one repeat US is indicated in 6 weeks or following a menstrual cycle to evaluate for resolution. Duplex (Doppler) scan (CPT® 93975 complete; CPT® 93976 limited) may be approved as an add-on to TV US (CPT® 76830). 3-D Rendering (CPT® 76377 or CPT® 76376) may be approved as an add-on.	† If initial imaging confirms hydrosalpinx or peritoneal cysts, advanced imaging is rarely indicated in these clinical scenarios. Send for physician review. † If initial ultrasound imaging (CPT® 76857 or CPT® 76856 and/or transvaginal CPT® 76830) equivocal for Hydrosalpinges, one repeat US is indicated in 6 weeks to evaluate for resolution. Duplex (Doppler) scan (CPT® 93975 complete; CPT® 93976 limited) may be approved as an add-on to TV US (CPT® 76830). 3-D Rendering (CPT® 76377 or CPT® 76376) may be approved as an add-on.

Pre-Menopausal – see table above

† A complex adnexal mass is any mass that is not considered to be a simple cyst. Description of a complex mass should include the presence or absence of septations, mural projections and/or papillary excrescences, and a comment on its vascularity.

† For women of reproductive age (Pre-Menopausal), evaluation may include a pregnancy test (a quantitative hCG may be necessary if an ectopic pregnancy is suspected), CBC, serial hematocrit measurements, and appropriate cultures.

† Symptomatic members often require immediate interventions (antibiotics, surgery, and/or expectant management).

† Ultrasound characteristics usually suggest the diagnosis (ectopic pregnancy, functional cysts, tuboovarian abscess (See PV-7: Pelvic Inflammatory Disease), hydrosalpinx, dermoid, endometrioma, hemorrhagic cyst and pedunculated fibroids (See PV-12: Leiomyomata/Uterine Fibroids) and direct the treatment.

† An ovarian mass suspicious for metastatic disease (e.g. from breast, uterine, colorectal or gastric cancer) should be evaluated based on the appropriate Oncology Imaging Guidelines.

Post-Menopausal – see table above

† A complex adnexal mass is any mass that is not considered to be a simple cyst. Description of complex mass should include presence or absence of septations, mural projections and/or papillary excrescences, and a comment on its vascularity.

† For post-menopausal women, most pelvic complex cysts or solid masses should be evaluated for surgical intervention and have tumor markers (i.e. CA-125) measured.

† If ultrasound is equivocal, advanced imaging may be appropriate for high risk treatment planning. Send for Medical Director Review.

† Some women for whom the usual management of a pelvic mass would include surgery may be at increased risk for perioperative morbidity and mortality. In such cases, repeat imaging may be a safer alternative than immediate surgery, although the frequency of follow-up imaging has not been determined.

† An ovarian mass suspicious for metastatic disease (e.g. from breast, uterine, colorectal or gastric cancer) should be evaluated based on the appropriate Oncology Imaging Guidelines.

PV-5.4: Screening for Ovarian Cancer/Suspected Ovary Cancer

For this condition imaging is medically necessary based on the following criteria:

† See Adult Oncology Imaging Policy (Policy #155 in the Radiology Section); ONC-21: Ovarian Cancer in the Oncology Imaging Guidelines

References
1. Papic JC, Finnell SME, Slaven JE, Billmire DF, Rescorla FJ, Leys CM. Predictors of ovarian malignancy in children: Overcoming clinical barriers of ovarian preservation. Journal of Pediatric Surgery. 2014;49(1):144-148. doi:10.1016/j.jpedsurg.2013.09.068.
2. Harris RD, Javitt MC, Glanc P, et al. ACR Appropriateness Criteria^® Clinically suspected adnexal mass. (Revised: 2018) https://acsearch.acr.org/docs/69466/Narrative/.
3. Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010;256(3):943-954. doi:10.1148/radiol.10100213.
4. Laing FC, Allison SJ. US of the Ovary and Adnexa: To Worry or Not to Worry? RadioGraphics. 2012;32(6):1621-1639. doi:10.1148/rg.326125512.
5. Sakhel K, Benson CB, Platt LD, Goldstein SR, Benacerraf BR. Begin With the Basics. Journal of Ultrasound in Medicine. 2013;32(3):381-388. doi:10.7863/jum.2013.32.3.381.
6. Benacerraf BR, Abuhamad AZ, Bromley B, et al. Consider ultrasound first for imaging the female pelvis. American Journal of Obstetrics and Gynecology. 2015;212(4):450-455. doi:10.1016/j.ajog.2015.02.015.
7. Practice Bulletin No. 174 Evaluation and Management of Adnexal masses. Obstetrics & Gynecology. 2016;128(5):1193-1195. doi:10.1097/aog.0000000000001763
8. Geomini PMAJ, Kluivers KB, Moret E, Bremer GL, Kruitwagen RFPM, Mol BWJ. Evaluation of Adnexal Masses With Three-Dimensional Ultrasonography. Obstetrics & Gynecology. 2006;108(5):1167-1175. doi:10.1097/01.aog.0000240138.24546.37.
9. Mansour GM, El-Lamie IK, El-Sayed HM, et al. Adnexal Mass Vascularity Assessed by 3-Dimensional Power Doppler: Does It Add to the Risk of Malignancy Index in Prediction of Ovarian Malignancy? International Journal of Gynecological Cancer. 2009;19(5):867-872. doi:10.1111/igc.0b013e3181a8335e.
10. Alcázar JL, Guerriero S, Laparte C, Ajossa S, Jurado M. Contribution of power Doppler blood flow mapping to gray-scale ultrasound for predicting malignancy of adnexal masses in symptomatic and asymptomatic women. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2011;155(1):99-105. doi:10.1016/j.ejogrb.2010.11.010.
11. Guerriero S, Alcazar JL, Ajossa S, et al. Transvaginal Color Doppler Imaging in the Detection of Ovarian Cancer in a Large Study Population. International Journal of Gynecological Cancer. 2010;20(5):781-786. doi:10.1111/igc.0b013e3181de9481.
13. Andreotti RF, Timmerman D, Benacerraf BR, et al. Ovarian-Adnexal Reporting Lexicon for Ultrasound: A White Paper of the ACR Ovarian-Adnexal Reporting and Data System Committee. Journal of the American College of Radiology. 2018;15(10):1415-1429. doi:10.1016/j.jacr.2018.07.004.

PV-6: Endometriosis

PV-6.1: Endometriosis

PV-6.1: Endometriosis

For this condition imaging is medically necessary based on the following criteria:

† TV ultrasound (CPT^® 76830) and/or Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) is then the first line diagnostic exam for pain or abnormality on exam.

® In most members, ultrasound followed by medical treatment or laparoscopy should be considered prior to advanced imaging.
® Laparoscopy remains the definitive test for diagnosis and evaluation of endometriosis in most members.

® Rectal involvement, rectovaginal endometriosis, deeply infiltrative bladder endometriosis, and cul-de-sac obliteration. MRI has been shown to accurately detect rectovaginal endometriosis and cul-de-sac obliteration in the more than 90% of cases
® To characterize complex adnexal masses as endometrioma if ultrasound equivocal.
® MRI can also enable complete lesion mapping prior to surgical excision of known endometriosis that was diagnosed during a previous surgery.

For this condition imaging is medically necessary based on the following criteria:

† Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830) is the initial study for imaging of suspected pelvic inflammatory disease (PID).

† CT Abdomen and Pelvis with contrast (CPT^® 74177) or CT Pelvis with contrast (CPT^® 72193) can be performed if:

® Ultrasound equivocal, or
® Extensive abscess formation as determined by ultrasound

References
1. Liu B, Donovan B, Hocking JS, Knox J, Silver B, Guy R. Improving Adherence to Guidelines for the Diagnosis and Management of Pelvic Inflammatory Disease: A Systematic Review. Infectious Diseases in Obstetrics and Gynecology. 2012;2012:1-6. doi:10.1155/2012/325108.
2. Jaiyeoba O, Soper DE. A Practical Approach to the Diagnosis of Pelvic Inflammatory Disease. Infectious Diseases in Obstetrics and Gynecology. 2011;2011:1-6. doi:10.1155/2011/753037.
3. Workowski KA. Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. Clinical Infectious Diseases. 2015;61(suppl 8). doi:10.1093/cid/civ771.
4. Practice Bulletin No. 174. Evaluation and Management of Adnexal Masses. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e210–26. doi:10.1097/aog.0000000000001768.


PV-8: Polycystic Ovary Syndrome

PV-8.1: Polycystic Ovary Syndrome

PV-8.1: Polycystic Ovary Syndrome

For this condition imaging is medically necessary based on the following criteria:

† Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830) may be performed based on history, exam, and laboratory findings suspicious for this disease

† Laboratory testing to be done prior to advanced imaging: Virilizing hormone levels (Testosterone and DHEAS). Disorders that mimic the clinical features of Polycystic ovary syndrome (PCOS) should be excluded by measuring: TSH, Prolactin, and 17-OHP (hydroxyprogesterone) levels. Others to consider based on the clinical presentation: Cortisol levels, ACTH, dexamethasone suppression testing, IGF-1, FSH, LH, estradiol.

† CT Abdomen without contrast (CPT^® 74150) is the initial study if elevated serum levels of androgens* are found and an adrenal etiology is suspected. CT Abdomen with (bolus arterial phase) contrast (CPT^® 74160) or chemical shift MRI Abdomen (CPT^® 74181) can be considered if this initial CT is equivocal, non-diagnostic, or concerning for malignancy. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-16: Adrenal Cortical Lesions in the Abdomen Imaging Guidelines

® *The adrenal gland preferentially secretes weak androgens such as DHEA and DHEAS. The ovary is the primary source of testosterone

† Polycystic ovary syndrome is the most common hormonal disorder among women of reproductive age, and is one of the leading causes of infertility.

† Ovaries are often enlarged and contain numerous small cysts located along the outer edge of each ovary. Signs and symptoms may include:

® Anovulation resulting in infrequent or prolonged menstrual periods.
® Excessive amounts or effects of androgenic (masculinizing) hormones (e.g. excess hair growth).
® Acne
® Obesity

PV-9: Infertility Evaluation, Female

PV-9.1: Infertility Evaluation, Female

PV-9.1: Infertility Evaluation, Female

For this condition imaging is medically necessary based on the following criteria:

† Initial work-up of infertility in female:

® Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and TV ultrasound (CPT^® 76830). If indicated, color Doppler (CPT^® 93975 or CPT^® 93976) and/or 3D imaging (CPT^® 76377 or CPT^® 76376) may be approved as an add-on. See PV-14: Uterine Anomalies.

® Hysterosalpingography (HSG) (CPT^® 74740).
¡ Injection of contrast through a catheter (CPT^® 58340)
® Sonohysterosalpingography (CPT^® 76831)
¡ Injection of contrast through a catheter (CPT^® 58340)

These guidelines are not intended for fertility follow-up and management.

If infertility is a covered service, the specialist may, over the course of several menstrual cycles, request multiple ultrasounds to follow follicular maturation and monitor endometrial thickness.

References
1. Committee Opinion No. 605. Primary Ovarian Insufficiency in Adolescents and Young Women. Obstetrics & Gynecology. 2014;124(1):193-197. doi:10.1097/01.aog.0000451757.51964.98. (July 2014, Reaffirmed 2018).
2. Steinkeler JA, Woodfield CA, Lazarus E, Hillstrom MM. Female Infertility: A Systematic Approach to Radiologic Imaging and Diagnosis. RadioGraphics. 2009;29(5):1353-1370. doi:10.1148/rg.295095047.
3. Vickramarajah S, Stewart V, Ree KV, Hemingway AP, Crofton ME, Bharwani N. Subfertility: What the Radiologist Needs to Know. RadioGraphics. 2017;37(5):1587-1602. doi:10.1148/rg.2017170053.

PV-10: Intrauterine Device (IUD) and Tubal Occlusion

PV-10.1: Intrauterine Device

PV-10.2: Tubal Occlusion Device

PV-10.1: Intrauterine Device

For this condition imaging is medically necessary based on the following criteria:

† Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830) if:

® Abnormal pelvic exam prior to IUD insertion, such as pelvic mass, irregularly shaped uterus, or enlarged uterus.
® Suspected complication at the time or immediately following IUD insertion:
¡ Abnormal IUD position
¡ Uterine perforation
¡ Severe pain
¡ Excessive bleeding
® Failure to improve with conservative treatment (7 days) such as antibiotics for cramping, light bleeding, and/or low grade fever following IUD placement.
® NOT as routine imaging to evaluate position prior to, immediately after and, for example, 6 weeks after insertion.

® If TV ultrasound is negative or non-diagnostic, Pelvic ultrasound (CPT^® 76856 or CPT^® 76857):
¡ If Pelvic ultrasound is negative or non-diagnostic, plain x-ray should be performed if pregnancy test is negative.
¡ Thereafter, CT Pelvis without contrast (CPT^® 72192) or CT Abdomen and Pelvis without contrast (CPT^® 74176) or MRI Pelvis without contrast (CPT^® 72195) can be considered when both ultrasound and plain x-ray are equivocal or non-diagnostic.

® Ultrasound can be performed to locate an intrauterine device (IUD) (CPT^® 76801 if a complete ultrasound has not yet been performed, CPT^® 76815 or CPT^® 76816 if a complete anatomic ultrasound was done previously, and/or CPT^® 76817 for a Transvaginal ultrasound).

For this condition imaging is medically necessary based on the following criteria:

† TV ultrasound (CPT^® 76830) and/or Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) if:

® Suspected complication of tubal occlusion device:
¡ Abnormal tubal occlusion device position
¡ Uterine perforation
¡ Severe pain
¡ Excessive bleeding

References
1. Boortz HE, Margolis DJA, Ragavendra N, Patel MK, Kadell BM. Migration of Intrauterine Devices: Radiologic Findings and Implications for Patient Care. RadioGraphics. 2012;32(2):335-352. doi:10.1148/rg.322115068.
2. Prabhakaran S, Chuang A. In-office retrieval of intrauterine contraceptive devices with missing strings. Contraception. 2011;83(2):102-106. doi:10.1016/j.contraception.2010.07.004.
3. Sakhel K, Benson CB, Platt LD, Goldstein SR, Benacerraf BR. Begin With the Basics. Journal of Ultrasound in Medicine. 2013;32(3):381-388. doi:10.7863/jum.2013.32.3.381.
4. Benacerraf BR, Abuhamad AZ, Bromley B, et al. Consider ultrasound first for imaging the female pelvis. American Journal of Obstetrics and Gynecology. 2015;212(4):450-455. doi:10.1016/j.ajog.2015.02.015.
5. Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol. 2017 Nov 2017 130(5):251-269. doi: 10.1097/AOG.0000000000002394.
6. Nowitzki KM, Hoimes ML, Chen B, Zheng LZ, Kim YH. Ultrasonography of intrauterine devices. Ultrasonography. 2015;34(3):183-194. doi:10.14366/usg.15010.
7. Guelfguat M, Gruenberg TR, Dipoce J, Hochsztein JG. Imaging of Mechanical Tubal Occlusion Devices and Potential Complications. RadioGraphics. 2012;32(6):1659-1673. doi:10.1148/rg.326125501.
8. Simpson W, Beitia L. Multimodality imaging of the Essure tubal occlusion device. Clinical Radiology. 2012;67(12). doi:10.1016/j.crad.2012.08.013.
9. Wong L, White N, Ramkrishna J, Júnior EA, Meagher S, Costa FDS. Three-dimensional imaging of the uterus: The value of the coronal plane. World Journal of Radiology. 2015;7(12):484. doi:10.4329/wjr.v7.i12.484.


PV-11: Pelvic Pain/Dyspareunia, Female

PV-11.1: Pelvic Pain/Dyspareunia, Female

PV-11.1: Pelvic Pain/Dyspareunia, Female

For this condition imaging is medically necessary based on the following criteria:

† Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830) initial imaging for unexplained pelvic pain and/or dyspareunia:

® Add Duplex Doppler (CPT^® 93975 or CPT^® 93976) if there is a suspicion of ovarian torsion on the initial ultrasound
® For chronic pelvic pain (pelvic pain for 6 months or greater), add Duplex Doppler (CPT^® 93975 or CPT^® 93976)
® If urethral diverticulum is suspected – See PV-13.2: Urethral Diverticula
® If endometriosis is suspected – See PV-6.1: Endometriosis

† If the initial ultrasound is equivocal for unexplained chronic pelvic pain, then the following can be considered:

® CT Pelvis with contrast (CPT^® 72193) for unexplained chronic pelvic pain.

® MRI Pelvis without contrast or with and without contrast (CPT^® 72195 or CPT^® 72197) or MRV Pelvis (CPT^® 72198), or CTV Pelvis (CPT^® 72191) for pelvic congestion.
¡ MRV Abdomen (CPT^® 74185) or CTV Abdomen (CPT^® 74175) if vascular intervention is planned.
■ CTV Abdomen and Pelvis (CPT^® 74174) is appropriate if CTV Pelvis has not been performed

® Pulsatile pelvic mass
® Incidental finding on prior imaging including ultrasound

® See Adult Peripheral Nerve Disorders Imaging Policy (Policy #157 in the Radiology Section); PN-2: Focal Neuropathy in the Peripheral Nerve Disorders Imaging Guidelines
® See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-24: Hip in the Musculoskeletal Imaging Guidelines

® Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830).
¡ CT Pelvis with contrast (CPT^® 72193) may be indicated if ultrasound is equivocal for complicated interstitial cystitis/bladder pain syndrome (when ordered by Specialist).

® The proctalgia syndromes are characterized by recurrent episodes of rectal/perineal pain, and may be due to sustained contractions of the pelvic floor musculature. Prior to advanced imaging, the evaluation of rectal/perineal pain should include:
¡ Digital rectal examination (assess for mass, fissures, hemorrhoids, etc.)
¡ Pelvic examination in females to exclude PID
¡ Recent flexible sigmoidoscopy or colonoscopy subsequent to the start of reported symptoms to exclude inflammatory conditions or malignancy
® Endoanal ultrasound (CPT^® 76872), MRI Pelvis with and without contrast (CPT^® 72197), or CT Pelvis with contrast (CPT^® 72193) are appropriate after the above studies have been performed or if laboratory or clinical information suggest infection, abscess, or inflammation

References
1. Hanno PM, Erickson D, Moldwin R, Faraday MM. Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome: AUA Guideline Amendment. Journal of Urology. 2015;193(5):1545-1553. doi:10.1016/j.juro.2015.01.086.
2. Shoskes DA, Nickel JC, Rackley RR, Pontari MA. Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes. Prostate Cancer and Prostatic Diseases. 2008;12(2):177-183. doi:10.1038/pcan.2008.42.
3. American College of Radiology (ACR), North American Society for Cardiovascular Imaging (NASCI), Society for Pediatric Radiology (SPR), ACR-NASCI-SPR practice parameter for the performance of body magnetic resonance angiography (MRA). Revised 2015 (Resolution 8). https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Body-MRA.pdf.
4. Steege JF, Siedhoff MT. Chronic Pelvic Pain. Obstetrics & Gynecology. 2014;124(3):616-629. doi:10.1097/aog.0000000000000417.
5. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG Clinical Guideline: Management of Benign Anorectal Disorders. The American Journal of Gastroenterology. 2014;109(8):1141-1157. doi:10.1038/ajg.2014.190.
6. Practice Bulletin No. 114: Management of Endometriosis. Obstetrics & Gynecology. 2010;116(1):223-236. doi:10.1097/aog.0b013e3181e8b073.
7. Practice Bulletin No. 119: Female Sexual Dysfunction. Obstet Gynecol. 2011 Apr:117(4):996-1007. doi:10.1097/aog.0b013e31821921ce.
8. Bookwalter CA, Vanburen WM, Neisen MJ, Bjarnason H. Imaging Appearance and Nonsurgical Management of Pelvic Venous Congestion Syndrome. RadioGraphics. 2019;39(2):596-608. doi:10.1148/rg.2019180159.
9. Bishop LA. Management of Chronic Pelvic Pain. Clinical Obstetrics and Gynecology. 2017;60(3):524-530. doi:10.1097/grf.0000000000000299


PV-12: Leiomyomata/Uterine Fibroids

PV-12.1: Leiomyomata

PV-12.1: Leiomyomata

For this condition imaging is medically necessary based on the following criteria:

Leiomyomata are also known as “fibroids.”

† Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830) can be performed for the following:

® Suspected leiomyomata
® Pre-operative prior to myomectomy
® Recurrent symptoms such as abnormal bleeding, pain, or pelvic pressure
® 3-D Rendering (CPT^® 76377 or CPT^® 76376) may be approved as an add-on if ultrasound is equivocal and intracavitary lesion is suspected, or if arterial embolization is being considered, or for surgical planning for myomectomy
® If ultrasound is equivocal for intracavitary lesion, Duplex (Doppler) scan (CPT^® 93975 complete; CPT^® 93976 limited) may be approved as an add-on to TV ultrasound (CPT^® 76830).

® Guide the treatment of myomas in an enlarged uterus with multiple myomas and/or precise myoma mapping is of clinical importance (for complex surgical planning)
® Equivocal sonohysterography or panoramic hysteroscopy with suspected submucous leiomyoma and imaging is needed for surgical planning
® Equivocal ultrasound prior to myomectomy
® Leiomyoma necrosis is suspected
® Uterine fibroid embolization is being considered
¡ If MRI is equivocal, MRA Pelvis (CPT^® 72198) or CTA Pelvis (CPT^® 72191) can be considered if requested by the interventional radiologist planning the arterial embolization
¡ There is no evidence to support interval MRI after embolization unless persistent or recurrent symptoms

1. Andrews RT, Spies JB, Sacks D, et al. Patient Care and Uterine Artery Embolization for Leiomyomata. Journal of Vascular and Interventional Radiology. 2009;20(7). doi:10.1016/j.jvir.2009.04.002.
2. Sakhel K, Benson CB, Platt LD, Goldstein SR, Benacerraf BR. Begin With the Basics. Journal of Ultrasound in Medicine. 2013;32(3):381-388. doi:10.7863/jum.2013.32.3.381.
3. Benacerraf BR, Abuhamad AZ, Bromley B, et al. Consider ultrasound first for imaging the female pelvis. American Journal of Obstetrics and Gynecology. 2015;212(4):450-455. doi:10.1016/j.ajog.2015.02.015.
4. Practice Bulletin No. 96: Alternatives to Hysterectomy in the Management of Leiomyomas. Obstetrics & Gynecology. 2008;112(2, Part 1):387-400. doi:10.1097/aog.0b013e318183fbab. (Reaffirmed 2019).
5. Turkgeldi E, Urman B, Ata B. Role of Three-Dimensional Ultrasound in Gynecology. Journal of Obstetrics and Gynaecology of India. 2014;65(3):146-154. doi:10.1007/s13224-014-0635-z.
6. Deshmukh SP, Gonsalves CF, Guglielmo FF, Mitchell DG. Role of MR Imaging of Uterine Leiomyomas before and after Embolization. RadioGraphics. 2012;32(6). doi:10.1148/rg.326125517.
7. Silberzweig JE, Powell DK, Matsumoto AH, Spies JB. Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques. Radiology. 2016;280(3):675-692. doi:10.1148/radiol.2016141693.


PV-13: Periurethral Cysts and Urethral Diverticula

PV-13.1: Periurethral cysts, Skene duct cyst and Gartner’s duct cyst

PV-13.2: Urethral Diverticula

PV-13.1: Periurethral cysts, Skene duct cyst and Gartner’s duct cyst

For this condition imaging is medically necessary based on the following criteria:

† Initial evaluation includes any of the following:

® Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830)

For this condition imaging is medically necessary based on the following criteria:

† Initial evaluation includes Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830)

† Urethrography, or CT Urethrography can be performed to evaluate any urethral abnormalities

† MRI Pelvis without and with contrast (CPT^® 72197) can be performed if ordered by operating surgeon if ultrasound equivocal for urethral abnormalities,

Practice Notes
Symptomatic infection of congenital periurethral glands can result in urethral diverticula. Symptoms include pain, urinary urgency, frequency of urination, recurrent urinary tract infection, dribbling after urination, or incontinence.

References

1. Lazarus E, Allen BC, Blaufox MD, et al. ACR Appropriateness Criteria^® Recurrent Lower Urinary Tract Infection in Women. Last review date: 2014. https://acsearch.acr.org/docs/69491/Narrative/.
2. Crescenze IM, Goldman HB. Female Urethral Diverticulum: Current Diagnosis and Management. Current Urology Reports. 2015;16(10). doi:10.1007/s11934-015-0540-8.
3. El-Nashar SA, Singh R, Bacon MM, et al. Female Urethral Diverticulum. Female Pelvic Medicine & Reconstructive Surgery. 2016;22(6):447-452. doi:10.1097/spv.0000000000000312.
4. Kawashima A, Sandler CM, Wasserman NF, Leroy AJ, King BF, Goldman SM. Imaging of Urethral Disease: A Pictorial Review. RadioGraphics. 2004;24(suppl_1). doi:10.1148/rg.24si045504.
5. Chaudhari VV, Patel MK, Douek M, Raman SS. MR Imaging and US of Female Urethral and Periurethral Disease. RadioGraphics. 2010;30(7):1857-1874. doi:10.1148/rg.307105054.


PV-14: Uterine Anomalies

PV-14.1: Uterine Anomalies

PV-14.1: Uterine Anomalies

For this condition imaging is medically necessary based on the following criteria:

† Initial evaluation includes Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) and/or TV ultrasound (CPT^® 76830). 3-D Rendering (CPT^® 76377 or CPT^® 76376) may be approved as an add-on if uterine anomaly is suspected on ultrasound

† Retroperitoneal ultrasound (CPT^® 76770 or CPT^® 76775) is indicated to evaluate for coexisting renal anomalies.

† MRI Pelvis without and with contrast (CPT^® 72197):

® Ultrasound defines a complex anomaly or is not definitive for a complex anomaly, or
® Requested for surgical planning

1. Sakhel K, Benson CB, Platt LD, Goldstein SR, Benacerraf BR. Begin With the Basics. Journal of Ultrasound in Medicine. 2013;32(3):381-388. doi:10.7863/jum.2013.32.3.381.
2. Benacerraf BR, Abuhamad AZ, Bromley B, et al. Consider ultrasound first for imaging the female pelvis. American Journal of Obstetrics and Gynecology. 2015;212(4):450-455. doi:10.1016/j.ajog.2015.02.015 .
3. Graupera B, Pascual MA, Hereter L, et al. Accuracy of three-dimensional ultrasound compared with magnetic resonance imaging in diagnosis of Müllerian duct anomalies using ESHRE-ESGE consensus on the classification of congenital anomalies of the female genital tract. Ultrasound in Obstetrics & Gynecology. 2015;46(5):616-622. doi:10.1002/uog.14825.
4. Chandler TM, Machan LS, Cooperberg PL, Harris AC, Chang SD. Müllerian duct anomalies: from diagnosis to intervention. The British Journal of Radiology. 2009;82(984):1034-1042. doi:10.1259/bjr/99354802.
5. ACR–SAR–SPR Practice Parameter for the Performance of Magnetic Resonance Imaging of the Soft Tissue Components of the Pelvis. Resolution 4. Revised 2015. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-softtissue-pel.pdf?la=en.


PV-15: Fetal MRI

PV-15.1: Fetal MRI

PV-15.2: Placenta Accreta/ Placenta Accreta Spectrum/ Placenta Percreta

PV-15.1: Fetal MRI

For this condition imaging is medically necessary based on the following criteria:

† See Obstetrical Ultrasound Policy (Policy #154 in the Radiology Section); OB-24.13: Fetal MRI in the Obstetrical Ultrasound Imaging Guidelines

† Fetal MRI (CPT^® 74712; CPT^® 74713 for each additional gestation)

® Do not report CPT^® 74712 and CPT^® 74713 in conjunction with CPT^® 72195, CPT^® 72196, CPT^® 72197

® Brain
¡ Congenital anomalies
■ ventriculomegaly
■ corpus callosal dysgenesis
■ holoprosencephaly
■ posterior fossa anomalies
■ malformations of cerebral cortical development
¡ Screening fetuses with a family risk for brain anomalies
■ tuberous sclerosis
■ corpus callosal dysgenesis
■ malformations of cerebral cortical development
¡ Vascular abnormalities
■ vascular malformations
■ hydranencephaly
■ intra-uterine cerebral vascular accident
® Spine
¡ Congenital anomalies
■ neural tube defects
■ sacrococcygeal teratomas
■ caudal regression/sacral agenesis
■ syringomyelia
■ vertebral anomalies
® Skull, face and neck
¡ Masses of the face and neck
■ venolymphatic malformations
■ hemangiomas
■ goiter
■ teratomas
■ facial clefts
¡ Airway obstruction
■ conditions that may impact parental counseling, prenatal management, delivery planning, and postnatal therapy
® Thorax
¡ Masses
■ congenital pulmonary airway malformations (congenital cystic adenomatoid malformation; sequestration, and congenital lobar emphysema);
■ congenital diaphragmatic hernia
■ effusion
¡ Volumetric assessment of lung
■ cases at risk for pulmonary hypoplasia secondary to oligohydramnios, chest mass, or skeletal dysplasias
® Abdomen, retroperitoneal and pelvis
¡ Mass
■ abdominal–pelvic cyst
■ tumors (e.g. hemangiomas, neuroblastomas, sacrococcygeal teratomas, and suprarenal or renal masses)
■ complex genitourinary anomalies (e.g. cloaca)
■ renal anomalies in cases of severe oligohydramnios
■ bowel anomalies such as megacystis microcolon
® Complications of monochorionic twins
¡ Delineation of vascular anatomy prior to laser treatment of twins
¡ Assessment of morbidity after death of a monochorionic co-twin
¡ Improved delineation of anatomy in conjoined twins

® Fetal surgery assessment
¡ Meningomyelocele
¡ Sacrococcygeal teratomas
¡ Processes obstructing the airway (e.g. neck mass or congenital high airway obstruction)
¡ Complications of monochorionic twins needing surgery
¡ Chest masses

For this condition imaging is medically necessary based on the following criteria:

® If the ultrasound is inconclusive or equivocal, send to Medical Director Review. Medical Director can approve MRI Pelvis without contrast (CPT^® 72195).

References
1. Saleem SN. Fetal MRI: An approach to practice: A review. Journal of Advanced Research. 2014;5(5):507-523. doi:10.1016/j.jare.2013.06.001.
2. American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR-SPR practice guideline for the safe and optimal performance of fetal magnetic resonance imaging (MRI). American College of Radiology (ACR). Revised 2015 (Resolution 11) https://www.acr.org/-/media/ACR/Files/Practice-Parameters/MR-Fetal.pdf.
3. Kilcoyne A, Shenoy-Bhangle AS, Roberts DJ, Sisodia RC, Gervais DA, Lee SI. MRI of Placenta Accreta, Placenta Increta, and Placenta Percreta: Pearls and Pitfalls. American Journal of Roentgenology. 2017;208(1):214-221. doi:10.2214/ajr.16.16281.
4. Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging. Obstetrics & Gynecology. 2014;123(5):1070-1082. doi:10.1097/aog.0000000000000245.
5. Belfort MA. Placenta accreta. American Journal of Obstetrics and Gynecology. 2010;203(5):430-439. doi:10.1016/j.ajog.2010.09.013.
6. Obstetric Care Consensus No. 7: Placenta Accreta Spectrum. Obstetrics & Gynecology. 2018;132(6). doi:10.1097/aog.0000000000002983.
7. Prayer D, Malinger G, Brugger PC, et al. ISUOG Practice Guidelines: performance of fetal magnetic resonance imaging. Ultrasound in Obstetrics & Gynecology. 2017;49(5):671-680. doi:10.1002/uog.17412.


PV-16: Molar Pregnancy and Gestational Trophoblastic Neoplasia (GTN)

PV-16.1: Molar Pregnancy and GTN

PV-16.1: Molar Pregnancy and GTN

For this condition imaging is medically necessary based on the following criteria:

† Molar pregnancy – once diagnosed on an Obstetrical Ultrasound members should undergo chest x-ray pre- and post-evacuation.

† Members with a molar pregnancy and rising hCG levels post evacuation and/or Gestational trophoblastic neoplasia should undergo the following for metastatic work-up.

® CT Chest (CPT^® 71260) and CT Abdomen and Pelvis (CPT^® 74177) with contrast
® MRI Brain without and with contrast (CPT^® 70553) if pulmonary metastasis

References
1. Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. The Lancet. 2010;376(9742):717-729. doi:10.1016/s0140-6736(10)60280-2.
2. National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2019 – August 9,2018. Gestational Trophoblastic Neoplasia, available at: https://www.nccn.org/professionals/physician_gls/pdf/gtn.pdf. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Central Nervous System Tumors Cancer V1.2018. – March 20, 2018©2018 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org


PV-17: Impotence/Erectile Dysfunction

PV-17.1: Impotence/Erectile Dysfunction

PV-17.1: Impotence/Erectile Dysfunction

For this condition imaging is medically necessary based on the following criteria:

† Imaging depends on the suspected disease:

® If erectile dysfunction suspected, Penile Doppler ultrasound (CPT^® 93980) can be performed²
® If large vessel vascular insufficiency is suspected following ultrasound, then CTA Pelvis with contrast (CPT^® 72191) may be indicated.
® Peyronie disease - Duplex ultrasound (CPT^® 93980) can be used to assess penile vasculature in Peyronie disease¹
® If male hypogonadism is suspected, See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-19: Pituitary in the Head Imaging Guidelines

References
1. Nehra A, Alterowitz R, Culkin DJ, et al. Peyronie’s Disease: AUA Guideline. Journal of Urology. 2015;194(3):745-753. doi:10.1016/j.juro.2015.05.098.


PV-18: Penis–Soft Tissue Mass

PV-18.1: Penis-Soft Tissue Mass

PV-18.1: Penis-Soft Tissue Mass

For this condition imaging is medically necessary based on the following criteria:

† Soft-tissue lesions of the penis should be evaluated initially by Penile ultrasound (CPT^® 76857)

† MRI Pelvis without and with contrast (CPT^® 72197) can be performed:

® Penile ultrasound (CPT^® 76857) is equivocal (not clearly benign, simple cyst), or
® Primary penile cancer is suspected.

® Ultrasound (CPT^® 76857) recommended,
® MRI Pelvis without and with contrast (CPT^® 72197) if ultrasound is equivocal and surgery or injection therapy is being contemplated

1. Singh AK, Saokar A, Hahn PF, Harisinghani MG. Imaging of Penile Neoplasms. RadioGraphics. 2005;25(6):1629-1638. doi:10.1148/rg.256055069.
2. Kirkham A. MRI of the penis. The British Journal of Radiology. 2012;85(special_issue_1). doi:10.1259/bjr/63301362.
3. Bertolotto M, Pavlica P, Serafini G, Quaia E, Zappetti R. Painful Penile Induration: Imaging Findings and Management. RadioGraphics. 2009;29(2):477-493. doi:10.1148/rg.292085117.
4. Prando D. New Sonographic Aspects of Peyronie Disease. Journal of Ultrasound in Medicine. 2009;28(2):217-232. doi:10.7863/jum.2009.28.2.217.
5. Bilgutay AN, Pastuszak AW. Peyronie’s Disease: A Review of Etiology, Diagnosis, and Management. Current Sexual Health Reports. 2015;7(2):117-131. doi:10.1007/s11930-015-0045-y.


PV-19: Male Pelvic Disorders

PV-19.1: Male Pelvic Disorders

PV-19.1: Male Pelvic Disorders

For this condition imaging is medically necessary based on the following criteria:

† Prostate Disorders

® Suspected Benign Prostatic Hypertrophy with obstructive voiding symptoms who have failed medication treatment can undergo:
¡ Transrectal ultrasound (CPT^® 76872) or Pelvis transabdominal ultrasound (bladder and prostate [CPT^® 76856 or CPT^® 76857]).
® Prostatitis with urinary retention or suspected abscess can undergo any of the following imaging studies:
¡ Transrectal ultrasound (CPT^® 76872) or Pelvis transabdominal ultrasound (bladder and prostate [CPT^® 76856 or CPT^® 76857]).
¡ CT Pelvis with contrast (CPT^® 72193) or MRI Pelvis without contrast (CPT^® 72195) or with and without contrast (CPT^® 72197) may be performed if ultrasound is equivocal for abscess or mass.

® MRI Pelvis without contrast (CPT^® 72195) can be considered to evaluate:
¡ Suspected hemorrhage within the seminal vesicles
¡ Radiation injury, neoplasia
¡ Failure of conservative treatment for 2 weeks
¡ Abnormal findings on Transrectal ultrasound.

® MRI Pelvis without and with contrast (CPT^® 72197) or Tc-99m scrotal scintigraphy (CPT^® 78761) if ultrasound is inconclusive.²

® The proctalgia syndromes are characterized by recurrent episodes of rectal/perineal pain, and may be due to sustained contractions of the pelvic floor musculature. Prior to advanced imaging, the evaluation of rectal/perineal pain should include:
¡ Digital rectal examination (assess for mass, prostate, fissures, hemorrhoids, etc.)
¡ Recent flexible sigmoidoscopy or colonoscopy subsequent to the start of reported symptoms to exclude inflammatory conditions or malignancy
® Endoanal ultrasound (CPT^® 76872), MRI Pelvis without and with contrast (CPT^® 72197), or CT Pelvis with contrast (CPT^® 72193) are appropriate after the above studies have been performed or if laboratory or clinical information suggest infection, abscess, or inflammation

® Pelvic ultrasound (CPT^® 76856 or CPT^® 76857).
¡ CT Pelvis with contrast (CPT^® 72193) may be indicated if ultrasound is equivocal for complicated interstitial cystitis/bladder pain syndrome (when ordered by Specialist)

† The causes of scrotal pain include torsion, epididymitis, strangulated hernia, segmental testicular infarction, trauma, testicular tumor, and idiopathic scrotal edema.¹

References

1. Nickel JC. Prostatitis. Canadian Urological Association Journal. 2011:306-315. doi:10.5489/cuaj.11211.
2. Hosseinzadeh K, Oto A, Allen BC, et al. ACR Appropriateness Criteria^® Hematospermia. Journal of the American College of Radiology. 2017;14(5). doi:10.1016/j.jacr.2017.02.023.
3. Sharp VJ, Takacs EB, and Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010 Aug 15;82(4):397-406. http://www.aafp.org/afp/2010/0815/p397.html.
4. Zhao H, Luo J, Wang D, et al. The Value of Transrectal Ultrasound in the Diagnosis of Hematospermia in a Large Cohort of Patients. Journal of Andrology. 2011;33(5):897-903. doi:10.2164/jandrol.111.013318.
5. Macdonald A, Burrell S. Infrequently Performed Studies in Nuclear Medicine: Part 2. Journal of Nuclear Medicine Technology. 2009;37(1):1-13. doi:10.2967/jnmt.108.057851.
6. Hartman MS, Leyendecker JR, Friedman B, et al. ACR Appropriateness Criteria^® Acute Onset of Scrotal Pain–Without Trauma, Without Antecedent Mass. Last review date: 2018. https://acsearch.acr.org/docs/69363/Narrative/.
7. Friedman B, Leyendecker JR, Blaufox MD, et al. ACR Appropriateness Criteria^® Lower Urinary Tract Symptoms: Suspicion of Benign Prostatic Hyperplasia Last review date: 2019. https://acsearch.acr.org/docs/69368/Narrative/.
8. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG Clinical Guideline: Management of Benign Anorectal Disorders. American Journal of Gastroenterology. 2014;109(8):1141-1157. doi:10.1038/ajg.2014.190.


PV-20: Scrotal Pathology

PV-20.1: Scrotal Pathology

PV-20.2: Para testicular and spermatic cord masses

PV-20.3: Testicular Microlithiasis

PV-20.1: Scrotal Pathology

For this condition imaging is medically necessary based on the following criteria:

† Scrotal ultrasound (CPT^® 76870) and/or Duplex (Doppler) ultrasound (CPT^® 93975 or CPT^® 93976) of the scrotum for initial evaluation of scrotal pain or mass

® MRI Pelvis without and with contrast (CPT^® 72197) or Tc-99m scrotal scintigraphy (CPT^® 78761) if ultrasound is inconclusive.^1,2

† Duplex (Doppler) ultrasound (CPT^® 76870 and/or CPT^® 93975 or CPT^® 93976) of the scrotum with color flow mapping in supine and upright positions to assess venous reflux into plexus pampiniformis if varicocele suspected (for example, in inguinal hernia evaluation).

® CT Abdomen and Pelvis with contrast (CPT^® 74177) for right-sided varicocele, when there is suspicion for intra-abdominal pathology

† The causes of scrotal pain may include torsion, epididymitis, strangulated hernia, segmental testicular infarction, trauma, testicular tumor, and idiopathic scrotal edema.¹

PV-20.2: Para testicular and spermatic cord masses

For this condition imaging is medically necessary based on the following criteria:

† Scrotal ultrasound (CPT^® 76870) is the appropriate initial imaging procedure,

® MRI Pelvis without and with contrast (CPT^® 72197), exploration and biopsy are additional considerations if ultrasound is inconclusive.

For this condition imaging is medically necessary based on the following criteria:

† Scrotal ultrasound (CPT^® 76870) for initial evaluation

† Annual Scrotal ultrasound (CPT^® 76870) follow-up until age 55, only if a risk factor is present which include:

® Family history of germ cell tumor
® Maldescent
® Orchidopexy
® Testicular atrophy

References
1. Hartman MS, Leyendecker JR, Friedman B, et al. ACR Appropriateness Criteria^® Acute Onset of Scrotal Pain–Without Trauma, Without Antecedent Mass. Last review date: 2018. https://acsearch.acr.org/docs/69363/Narrative/.
2. Kim W, Rosen MA, Langer JE, Banner MP, Siegelman ES, Ramchandani P. US–MR Imaging Correlation in Pathologic Conditions of the Scrotum. RadioGraphics. 2007;27(5):1239-1253. doi:10.1148/rg.275065172.
3. Wolfman DJ, Marko J, Gould CF, Sesterhenn IA, Lattin GE. Mesenchymal Extratesticular Tumors and Tumorlike Conditions:From the Radiologic Pathology Archives. RadioGraphics. 2015;35(7):1943-1954. doi:10.1148/rg.2015150179.
4. Tan IB, Ang KK, Ching BC, Mohan C, Toh CK, Tan MH. Testicular microlithiasis predicts concurrent testicular germ cell tumors and intratubular germ cell neoplasia of unclassified type in adults. Cancer. 2010;116(19):4520-4532. doi:10.1002/cncr.25231.
5. Decastro BJ, Peterson AC, Costabile RA. A 5-Year Followup Study of Asymptomatic Men With Testicular Microlithiasis. The Journal of Urology. 2008;179(4):1420-1423. doi:10.1016/j.juro.2007.11.080.
6. Winter TC, Kim B, Lowrance WT, Middleton WD. Testicular Microlithiasis: What Should You Recommend? American Journal of Roentgenology. 2016;206(6):1164-1169. doi:10.2214/ajr.15.15226.
7. Brazao CADG, Pierik F, Oosterhuis J, Dohle G, Looijenga L, Weber R. Bilateral Testicular Microlithiasis Predicts the Presence of the Precursor of Testicular Germ Cell Tumors in Subfertile Men. The Journal of Urology. 2004;171(1):158-160. doi:10.1097/01.ju.0000093440.47816.88.
8. Richenberg J, Belfield J, Ramchandani P, et al. Testicular microlithiasis imaging and follow-up: guidelines of the ESUR scrotal imaging subcommittee. European Radiology. 2014;25(2):323-330. doi:10.1007/s00330-014-3437-x.
9. Richenberg J, Brejt N. Testicular microlithiasis: is there a need for surveillance in the absence of other risk factors? European Radiology. 2012;22(11):2540-2546. doi:10.1007/s00330-012-2520-4.
10. AIUM Practice Guideline for the Performance of Scrotal Ultrasound Examinations. Journal of Ultrasound in Medicine. 2015;34(8):1-5. doi:10.7863/ultra.34.8.15.13.0006.
11. Parenti GC, Feletti F, Carnevale A, Uccelli L, Giganti M. Imaging of the scrotum: beyond sonography. Insights Imaging. 2018;9(2):137-148. doi:10.1007/s13244-017-0592-z.


PV-21: Fistula in Ano

PV-21.1: Fistula in Ano

PV-21.2: Perirectal Abscess

PV-21.1: Fistula in Ano

For this condition imaging is medically necessary based on the following criteria:

† MRI Pelvis without and with contrast (CPT^® 72197) is the preferred study.

® If MRI cannot be performed, endoscopic ultrasound is superior, and thus preferential, to CT imaging.
® CT Pelvis with contrast (CPT^® 72193) is an inferior study to either of the above (accuracy of endoscopic ultrasound vs. CT for perianal fistula is 82% vs. 24%) and its use should be limited only to those circumstances in which MRI or endoscopic ultrasound cannot be performed.

For this condition imaging is medically necessary based on the following criteria:

† MRI Pelvis without and with contrast (CPT^® 72197) is the preferred study

® CT Pelvis with contrast (CPT^® 72193) can be approved as an alternative study if desired.

References

1. Ziech M, Felt–Bersma R, Stoker J. Imaging of Perianal Fistulas. Clinical Gastroenterology and Hepatology. 2009;7(10):1037-1045. doi:10.1016/j.cgh.2009.06.030.
2. Vogel JD, Johnson EK, Morris AM, et al. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Diseases of the Colon & Rectum. 2016;59(12):1117-1133. doi:10.1097/dcr.0000000000000733.
3. Schratter-Sehn AU, Lochs H, Vogelsang H, Schurawitzki H, Herold C, Schratter M. Endoscopic Ultrasonography versus Computed Tomography in the Differential Diagnosis of Perianorectal Complications in Crohns Disease. Endoscopy. 1993;25(09):582-586. doi:10.1055/s-2007-1010409.
4. Berman L. Utility of magnetic resonance imaging in anorectal disease. World Journal of Gastroenterology. 2007;13(23):3153. doi:10.3748/wjg.v13.i23.3153.


PV-22: Incontinence/Pelvic Organ Prolapse

PV-22.1: Urinary Incontinence – Initial Imaging

PV-22.2: Urinary Incontinence – Further Imaging

PV-22.3: Pelvic Prolapse

PV-22.4: Fecal Incontinence

PV-22.1: Urinary Incontinence – Initial Imaging

For this condition imaging is medically necessary based on the following criteria:

† Initial Imaging, associated with other evaluations, are:

® Non-Neurogenic Incontinence
¡ Measurements of post void residual urine by Bladder ultrasound (CPT^® 51798) OR Bladder catheterization.
¡ In addition to post void residual volume determination, screening for UTI should be considered
¡ Urodynamic studies for complex conditions or unclear case of incontinence after basic evaluation.
¡ Preoperative multichannel urodynamic testing is not needed in women with stress incontinence (uncomplicated) prior to initial incontinence surgery
® Neurogenic Incontinence
¡ Ultrasound urinary tract (CPT^® 76770 or CPT^® 76775) and/or urodynamic studies.

PV-22.2: Urinary Incontinence – Further Imaging

For this condition imaging is medically necessary based on the following criteria:

† CT Abdomen and/or Pelvis, contrast as requested, can be performed for the following:

® Abnormality on ultrasound that requires further evaluation
® Complicated incontinence
® Suspected fistulae
® Detecting ectopic ureters if ultrasound is non-diagnostic
® Pre-operative planning for complicated incontinence when ordered by the operating physician

Practice Notes

† Complicated urinary incontinence includes:

® Failed conservative treatment
® Pain or dysuria
® Hematuria
® Recurrent infection
® Previous radical pelvic surgery
® Suspected fistula
® Suspected mass
® Previous pelvic or prostate irradiation

For this condition imaging is medically necessary based on the following criteria:

† Transvaginal (TV) ultrasound (CPT^® 76830) is the initial study of choice.

® Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) can be performed if requested as a complimentary study to the TV ultrasound.

† MRI Pelvis (CPT^® 72195 or CPT^® 72197) may be indicated for the following:

® Pelvic floor anatomy and pelvic organ prolapse evaluations if exam and TV ultrasound (CPT^® 76830) and/or Pelvic ultrasound (CPT^® 76856 or CPT^® 76857) are equivocal; or
® Pre-operative planning for complex organ prolapse when ordered by the operating physician; or
® Persistent incontinence following surgery

® Diagnostic evaluation for mesh and graft complications may include colonoscopy, cystoscopy, urodynamics, and radiologic imaging
® All requests are sent to Medical Director review

PV-22.4: Fecal Incontinence

For this condition imaging is medically necessary based on the following criteria:

The evaluation of fecal incontinence generally proceeds as follows:

† Determine the severity of the incontinence (Bristol Stool Scale, Fecal Incontinence Severity Index, etc.)

† History and Physical to include digital rectal examination and perianal pinprick (to assess for neurogenic causes).

† Trial of conservative management

† Diagnostic Testing if symptoms persist to include:

® Ano-rectal Manometry
® Balloon Expulsion Test
® Endoanal ultrasound (CPT^® 76872) to confirm sphincter defects in members with suspected sphincter injury (e.g. history of vaginal delivery or anorectal surgery)
® MRI Pelvis (CPT^® 72197) or MRI Defecography (CPT^® 72195) can be considered if:
¡ Ano-rectal manometry suggests weak sphincter pressures AND/OR there is an abnormal balloon expulsion test
AND
¡ There has been a failure of a recent trial of conservative management
AND
¡ Surgery is being considered

However, guidelines adopted by the American Society of Colon and Rectal Surgeons note that “Endoanal ultrasound is a useful and sensitive tool in the evaluation of members with FI (fecal incontinence), especially when there is a history of vaginal delivery or anorectal surgery. Ultrasound can reliably identify internal and external sphincter defects that may be associated with sphincter dysunction.” In addition, the guidelines note “Other modalities (eg, MRI) have shown substantial interobserver variability and, at this point, are likely inferior to ultrasound imaging, but they may provide additional information where endoanal ultrasound is unavailable.”

References

1. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG Clinical Guideline: Management of Benign Anorectal Disorders. American Journal of Gastroenterology. 2014;109(8):1141-1157. doi:10.1038/ajg.2014.190.
2. Rao SS. Advances in Diagnostic Assessment of Fecal Incontinence and Dyssynergic Defecation. Clinical Gastroenterology and Hepatology. 2010;8(11). doi:10.1016/j.cgh.2010.06.004.
3. Woodfield CA, Krishnamoorthy S, Hampton BS, Brody JM. Imaging Pelvic Floor Disorders: Trend Toward Comprehensive MRI. American Journal of Roentgenology. 2010;194(6):1640-1649. doi:10.2214/ajr.09.3670.
4. Practice Bulletin No. 155. Urinary Incontinence in Women. Obstetrics & Gynecology. 2015;126(5). doi:10.1097/aog.0000000000001148. (Reaffirmed in 2018).
5. Practice Bulletin No. 185. Pelvic Organ Prolapse. Obstetrics & Gynecology. 2017;130(5):1170-1172. doi:10.1097/00006250-201711000-00046.
6. Committee Opinion No. 694. Management of Mesh and Graft Complications in Gynecologic Surgery. Obstetrics & Gynecology. 2017;129(4). doi:10.1097/aog.0000000000002022.
7. Paquette IM, Varma MG, Kaiser AM, Steele SR, Rafferty JF. The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Treatment of Fecal Incontinence. Diseases of the Colon & Rectum. 2015;58(7):623-636. doi:10.1097/dcr.0000000000000397.


PV-23: Patent Urachus

PV-23.1: Patent Urachus

PV-23.1: Patent Urachus

For this condition imaging is medically necessary based on the following criteria:

† Drainage from the umbilicus, redness around umbilicus, abdominal pain, or urinary tract infection from persistent fetal connection between the bladder and the umbilicus can be evaluated by:

® Ultrasound (CPT^® 76856 or CPT^® 76857 and/or CPT^® 76700 or CPT^® 76705) or voiding cystourethrography (VCUG) (CPT^® 74455) for suspected patent urachus
® CT Pelvis with contrast (CPT^® 72193) or MRI Pelvis without contrast (CPT^® 72195) or with and without contrast (CPT^® 72197) may be performed if the ultrasound is equivocal or if additional imaging is needed for surgical planning if there is a suspected urachal carcinoma or other urachal abnormality.

For this condition imaging is medically necessary based on the following criteria:

† Bladder masses, stones, and diverticuli can be found on ultrasound, CT or MRI incidentally. Symptoms may include hematuria, urgency, frequency, chronic urinary infection, obstruction or urinary retention. Bladder masses can be evaluated by:

® CT Pelvis without contrast (CPT^® 72192) for suspected bladder stone KUB, if translucent and surgery is planned
® CT Pelvis with and without contrast (CPT^® 72194) if suspected bladder diverticuli,
® CT Urogram (CPT^® 74178) for suspected carcinoma
® MRI Pelvis with and without contrast (CPT^® 72197) may be indicated for uncommon cell lines such as rhabdomyosarcoma, and leiomyosarcoma

For this condition imaging is medically necessary based on the following criteria:

† Nuclear Medicine

® Nuclear medicine studies are rarely used in imaging of the pelvis, but are indicated in some clinical circumstances, including the following:
¡ Lymph system mapping (CPT^® 78195) is indicated for lower extremity lymphedema with recent negative Doppler ultrasound, or a history of Milroy’s disease or prior pelvic lymph node dissection.

† Radiopharmaceutical Voiding Cystogram (CPT^® 78730) with Urinary Bladder Residual study is indicated for suspicion of urinary retention and a recent non-diagnostic ultrasound.

References
1. Mandell GA, Eggli DF, Gilday DL, et al. Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children, version 3.0 approved January 25, 2003. http://snmmi.files.cms-plus.com/docs/pg_ch32_0703.pdf.
2. Peters CA, Skoog SJ, Arant Jr BS, et al. Management and Screening of Primary Vesicoureteral Reflux in Children (2017): AUA guideline. American Urology Association. (Published 2010. Reviewed and validity confirmed 2017) http://www.auanet.org/guidelines/vesicoureteral-reflux-guideline.
3. Fettich J, Colarinha P, Fischer S, et al. Guidelines for direct radionuclide cystography in children. European Journal of Nuclear Medicine and Molecular Imaging. 2003;30(5). doi:10.1007/s00259-003-1137-x.
4. MacDonald A, Burrell S. Infrequently Performed Studies in Nuclear Medicine: Part 2. Journal of Nuclear Medicine Technology. 2009;37(1):1-13. doi:10.2967/jnmt.108.057851.
5. Tekgül S, Riedmiller H, Gerharz E, et al. Guidelines on Paediatric Urology. European Association of Urology. Update March 2013. https://uroweb.org/wp-content/uploads/22-Paediatric-Urology_LR.pdf.
6. Hartman MS, Leyendecker JR, Friedman B, et al. ACR Appropriateness Criteria^® Acute Onset of Scrotal Pain–Without Trauma, Without Antecedent Mass. Last review date: 2018. https://acsearch.acr.org/docs/69363/Narrative/.
7. Altinkilic B, Pilatz A, Weidner W. Detection of Normal Intratesticular Perfusion Using Color Coded Duplex Sonography Obviates Need for Scrotal Exploration in Patients with Suspected Testicular Torsion. Journal of Urology. 2013;189(5):1853-1858. doi:10.1016/j.juro.2012.11.166.



Medicare Coverage:
Medicare Advantage Products follow CMS National Coverage Determinations, Local Coverage Determinations and other CMS Guidance (eg, Medicare Benefit Policy Manual, Medicare Learning Network Articles (MLN Matters Articles), Medicare Claims Processing Manual)). If CMS does not have a coverage or noncoverage position on a service, Medicare Advantage Products will follow Horizon BCBSNJ Medical Policy. If there is no CMS Guidance and no Horizon BCBSNJ Medical Policy, then eviCore Diagnostic Advanced Imaging Guidelines will be applied.

NCDs available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx

LCDs available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46

DME LCDS available to be accessed at Noridian Healthcare Services, LLC, (DME MAC), Local Coverage Determinations (LCDs) search page: https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=389&ContrVer=1&CntrctrSelected=389*1&s=38&DocType=All&bc=AggAAAAAAAAAAA%3d%3d&#ResultsAnchor.

Providers are responsible for reviewing CMS Medicare Coverage Center Guidance and in the event of a conflict between the Medicare Coverage section of the medical policy and the CMS Medicare Coverage Center Guidance, the CMS Medicare Coverage Center Guidance will control.

Medicaid Coverage:

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Adult Pelvis Imaging Policy
Pelvis Imaging Policy, Adult
Computed Tomography, Pelvis, Adult
CT, Pelvis, Adult
Computed Tomography Angiography, Pelvis, Adult
CTA, Pelvis, Adult
Magnetic Resonance Imaging, Pelvis, Adult
MRI, Pelvis, Adult
Magnetic Resoance Angiography, Pelvis, Adult
MRA, Pelvis, Adult
Positron Emission Tomography, Pelvis, Adult
PET, Pelvis, Adult
Nuclear Medicine Imaging, Pelvis, Adult
Transvaginal Ultrasound, Adult
Ultrasound, Pelvis, Adult
Duplex Scan, Pelvis, Adult
Doppler, Pelvis, Adult
Radiopharmaceutical Nuclear Imaging, Pelvis, Adult
Radiopharmaceutical Voiding Cystogram

References:


Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*