PEDPV-1.1: Pediatric Pelvis Imaging Age Considerations

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

Many conditions affecting the pelvis in the pediatric population are different diagnoses than those occurring in the adult population. For those diseases which occur in both pediatric and adult populations, minor differences may exist in management due to patient age, comorbidities, and differences in disease natural history between children and adults.

† Patients who are <18 years old should be imaged according to the Pediatric Pelvis Imaging Guidelines and patients who are ≥18 years should be imaged according to the Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); Adult Pelvis Imaging Guidelines, except where directed otherwise by a specific guideline section.

PEDPV-1.2: Pediatric Pelvis Imaging Appropriate Clinical Evaluation

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

† A recent (within 60 days) face to face evaluation including a detailed history, physical examination, and appropriate laboratory studies should be performed prior to considering the use of an advanced imaging (CT, MRI, Nuclear Medicine) procedure. An exception can be made if the patient is undergoing guideline-supported, scheduled follow-up imaging evaluation.

† Unless otherwise stated in a specific guideline section, the use of advanced imaging to screen asymptomatic patients for disorders involving the pelvis is not supported. Advanced imaging of the pelvis should only be approved in patients who have documented active clinical signs or symptoms of disease involving the pelvis.

† Unless otherwise stated in a specific guideline section, repeat imaging studies of the pelvis are not necessary unless there is evidence for progression of disease, new onset of disease, and/or documentation of how repeat imaging will affect patient management or treatment decisions.

PEDPV-1.3: Pediatric Pelvis Imaging Modality General Considerations

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

† Ultrasound

® Ultrasound should be the initial imaging in most pelvic conditions to rule out those situations that do not require additional advanced imaging.
® For those patients who do require advanced imaging after ultrasound, ultrasound can be very beneficial in selecting the proper modality, body area, image sequences, and contrast level that will provide the most definitive information for the patient.
® CPT^® codes vary by body area and presence or absence of Doppler imaging and are included in the table at the beginning of this guideline.
® Transabdominal ultrasound is appropriate in all pediatric patients.
® Transvaginal (TV) ultrasound is appropriate in pediatric patients who are sexually active or use a tampon and consent to the study. Ultrasound (complete CPT^® 76856 or, limited CPT^® 76857) should substitute for TV in pediatric patients or non-sexually active adult females.

® MRI Pelvis is generally performed without and with contrast (CPT^® 72197) unless the patient has a documented contraindication to gadolinium or otherwise stated in a specific guideline section.
® Due to the length of time required for MRI acquisition and the need to minimize patient movement, anesthesia is usually required for almost all infants (except neonates) and young children (age <7 years) as well as older children with delays in development or maturity. This anesthesia may be administered via oral or intravenous routes. In this patient population, MRI sessions should be planned with a goal of minimizing anesthesia exposure by adhering to the following considerations:
¡ MRI procedures can be performed without and/or with contrast use as supported by these condition-based guidelines. If intravenous access will already be present for anesthesia administration and there is no contraindication for using contrast, imaging without and with contrast may be appropriate if requested. By doing so, the requesting provider may avoid repetitive anesthesia administration to perform an MRI with contrast if the initial study without contrast is inconclusive.
■ Recent evidence based literature demonstrates the potential for gadolinium deposition in various organs including the brain, after the use of MRI contrast.
■ The U.S. Food and Drug Administration (FDA) has noted that there is currently no evidence to suggest that gadolinium retention in the brain is harmful and restricting gadolinium-based contrast agents (GBCAs) use is not warranted at this time. It has been recommended that GBCA use should be limited to circumstances in which additional information provided by the contrast agent is necessary and the necessity of repetitive MRIs with GBCAs should be assessed.
¡ If multiple body areas are supported by Horizon BCBSNJ guidelines for the clinical condition being evaluated, MRI of all necessary body areas should be obtained concurrently in the same anesthesia session.
® The presence of surgical hardware or implanted devices may preclude MRI.
® The selection of best examination may require coordination between the provider and the imaging service.

® CT Pelvis typically extends from the iliac crest to the ischial tuberosities, and CT Abdomen and Pelvis extends from the dome of the diaphragm through the ischial tuberosities.
¡ In general, CT Pelvis is appropriate when evaluating solid pelvic organs.
¡ In general, CT Abdomen and Pelvis is appropriate when evaluating inflammatory or infections processes, hematuria, or conditions which appear to involve both the abdomen and the pelvis.
¡ In some cases, especially in follow-up of a known finding, it may be appropriate to limit the exam to the region of concern to reduce radiation exposure.
® The contrast level in pediatric CT imaging is specific to the clinical indication, as listed in the specific guideline sections.
® CT Pelvis or Abdomen and Pelvis may be indicated for further evaluation of abnormalities suggested on prior US or MRI Procedures.
® CT may be appropriate without prior MRI or US, as indicated in specific sections of these guidelines.
® CT should not be used to replace MRI in an attempt to avoid sedation unless listed as a recommended study in a specific guideline section.
® The selection of best examination may require coordination between the provider and the imaging service.

® Nuclear medicine studies are rarely used in imaging of the pediatric pelvis, but are indicated in rare 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.

References

1. Berland LL, Cernigliaro JG, Ho VB, et al. ACR Practice parameter for performing and interpreting magnetic resonance imaging (MRI). American College of Radiology. Revised 2017.
2. Faerber EN, Abramson SJ, Benator RM, et al. ACR–ASER–SCBT-MR–SPR Practice parameter for the performance of pediatric computed tomography (CT). American College of Radiology. Revised 2014.
3. Ing C, Dimaggio C, Whitehouse A, et al. Long-term Differences in Language and Cognitive Function After Childhood Exposure to Anesthesia. Pediatrics. 2012;130(3). doi:10.1542/peds.2011-3822.
4. Monteleone M, Khandji A, Cappell J, Lai WW, Biagas K, Schleien C. Anesthesia in Children. Journal of Neurosurgical Anesthesiology. 2014;26(4):396-398. doi:10.1097/ana.0000000000000124.
5. Dimaggio C, Sun LS, Li G. Early Childhood Exposure to Anesthesia and Risk of Developmental and Behavioral Disorders in a Sibling Birth Cohort. Anesthesia & Analgesia. 2011;113(5):1143-1151. doi:10.1213/ane.0b013e3182147f42.
6. 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.
7. FDA Drug Safety Communication: FDA identifies no harmful effects to date with brain retention of gadolinium-based contrast agents for MRIs; review to continue. FDA Drug Safety Communication. May 22, 2017.
8. Siegel MJ. Pediatric Sonography. 5th ed. Philadelphia: Wolters Kluwer. p 513-556.

PEDPV-2: Abnormal Uterine Bleeding

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

† Abnormal uterine bleeding imaging indications in pediatric patients are very similar to those for adult patients. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-2: Abnormal Uterine Bleeding in the Pelvis Imaging Guidelines.

† The causes of vaginal bleeding in children differ from those in adolescents. Vaginal bleeding after the first week or so of life but before menarche is always abnormal and warrants evaluation. Common conditions before normal menarche include vaginal foreign bodies, infections, precocious puberty, and estrogen exposure. After menarche, pregnancy and excessive menstrual bleeding (dysfunction) must be considered.

† Pediatric-specific imaging considerations include the following:

® Transabdominal ultrasound is appropriate in all pediatric patients.
® Transvaginal (TV) ultrasound is appropriate in pediatric patients who are sexually active or use a tampon and consent to the study. Transvaginal ultrasound is generally not appropriate in pediatric patients or in patients who have never been sexually active.
® MRI Pelvis without contrast or without and with contrast (CPT^® 72195 or CPT^® 72197) is indicated if ultrasound is inconclusive.

PEDPV-3: Pelvic Inflammatory Disease (PID)

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

† Pelvic inflammatory disease imaging indications in pediatric patients are very similar to those for adult patients. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-7: Pelvic Inflammatory Disease (PID) in the Pelvis Imaging Guidelines.

† Pediatric-specific imaging considerations include the following:

® Transabdominal ultrasound is appropriate in all pediatric patients.
® Transvaginal (TV) ultrasound is appropriate in pediatric patients who are sexually active or use a tampon and consent to the study. Transvaginal ultrasound is generally not appropriate in patients who are pre-pubescent or victims of abuse.
® MRI Pelvis without contrast (CPT^® 72195) or without and with contrast (CPT^® 72197) is indicated if US is inconclusive.
® CT Pelvis with contrast (CPT^® 72193) is indicated if MRI is not readily available.

PEDPV-4: Amenorrhea

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

† Girls with primary amenorrhea and any of the following should be evaluated initially with pelvic ultrasound (CPT^® 76856 or CPT^® 76857):

® Amenorrhea is usually primary and refers to absence of menstrual periods by age 16.
¡ Normal pubertal development and negative pregnancy test.
¡ Transabdominal ultrasound is appropriate in all pediatric patients.
■ Transvaginal (TV) ultrasound is appropriate in pediatric patients who are sexually active or use a tampon and consent to the study. Transvaginal ultrasound (CPT^® 76830) can also be approved if requested for better view of genitourinary anomalies in sexually active females.
¡ Delayed puberty with follicle-stimulating hormone (FSH) or luteinizing hormone (LH) that is elevated for the patient’s age and Tanner stage.

® Evaluation of congenital anomalies of the uterus and/or urinary system identified on abdominal and pelvic ultrasound (CPT^® 76700 and CPT^® 76856) in order to better define complex anatomy.
® Preoperative planning in girls with distention of the vagina by fluid (hydrocolpos) or blood (hematocolpos) due to congenital vaginal obstruction.

1. Langer JE, Oliver ER, Lev-Toaff AS, Coleman BG. Imaging of the Female Pelvis through the Life Cycle. RadioGraphics. 2012;32(6):1575-1597. doi:10.1148/rg.326125513.
2. Suscato GS and Burstein GR. Amenorrhea. Nelson Textbook of Pediatrics, chapter 116. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016; 963-965.
3. Cohen HL and Raju AD. Amenorrhea and abnormalities of puberty. Caffey’s Pediatric Diagnostic Imaging, chapter 128. eds Brian Coley, Elsevier Saunders, Philadelphia PA, 12^th edition. 2013; 12.
4. Behr SC, Courtier JL, Qayyum A. Imaging of Müllerian Duct Anomalies. RadioGraphics. 2012;32(6). doi:10.1148/rg.326125515.

PEDPV-5: Endometriosis

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

† Endometriosis imaging indications in pediatric patients are very similar to those for adult patients. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-6: Endometriosis in the Pelvis Imaging Guidelines.

† Pediatric-specific imaging considerations include:

® Transabdominal ultrasound is appropriate in all pediatric patients.
® Transvaginal (TV) ultrasound is appropriate in pediatric patients who are sexually active or use a tampon and consent to the study. Transvaginal ultrasound is generally not appropriate in patients who are pre-pubescent or have never been sexually active.

PEDPV-6: Suspected Adnexal Mass

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

† Suspected adnexal mass imaging indications in pediatric patients are very similar to those for adult patients. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-5: Adnexal Mass/Ovarian Cysts in the Pelvis Imaging Guidelines. Ultrasound is the first study indicated for evaluation of a suspected adnexal mass.

† Pediatric-specific imaging considerations include the following:

® Transabdominal ultrasound is appropriate in all pediatric patients.
® Transvaginal (TV) Ultrasound is appropriate in pediatric patients who are sexually active or use a tampon and consent to the study. Transvaginal ultrasound is generally not appropriate in patients who are pre-pubescent or have never been sexually active.
® Adnexal masses with a solid component in patients, age ≥15 years, should be imaged according to Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-10: Pediatric Germ Cell Tumors in the Pediatric Oncology Imaging Guidelines.

PEDPV-7: Pelvic Pain/Dyspareunia, and Ovarian Torsion

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

† Pelvic Pain/Dyspareunia imaging indications in pediatric members are identical to those for adult members. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-11: Pelvic Pain/Dyspareunia, Female for imaging guidelines.

† Ovarian torsion in children is typically associated with a normal ovary. Spontaneous torsion of a normal ovary is more common than torsion caused by a lead mass, such as a cyst or tumor. Torsion involves both the ovary and fallopian tube and typically presents with acute of onset of lower abdominal pain, often associated with nausea or vomiting.

® Transabdominal ultrasound is appropriate in all pediatric patients.
® Transvaginal (TV) ultrasound is appropriate in pediatric patients who are sexually active or use a tampon and consent to the study. Transvaginal ultrasound is generally not appropriate in patients who are pre-pubescent or have never been sexually active.

1. Naffaa L, Deshmukh T, Tumu S, Johnson C, Boyd KP, Meyers AB. Imaging of Acute Pelvic Pain in Girls: Ovarian Torsion and Beyond ☆. Current Problems in Diagnostic Radiology. 2017;46(4):317-329. doi:10.1067/j.cpradiol.2016.12.010.
2. Siegel MJ. Pediatric Sonography. 5th ed. Philadelphia: Wolters Kluwer. p 513-556.
3. Sintim-Damoa A, Majmudar AS, Cohen HL, Parvey LS. Pediatric Ovarian Torsion: Spectrum of Imaging Findings. RadioGraphics. 2017;37(6):1892-1908. doi:10.1148/rg.2017170026.

PEDPV-8: Polycystic Ovary Syndrome

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

† Polycystic ovary syndrome imaging indications in pediatric members are identical to those for adult members. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-8: Polycystic Ovary Syndrome for imaging guidelines.

Reference

1. Fondin M, Rachas A, Huynh V, et al. Polycystic Ovary Syndrome in Adolescents: Which MR Imaging–based Diagnostic Criteria? Radiology. 2017;285(3):961-970. doi:10.1148/radiol.2017161513.

PEDPV-9: Periurethral Cysts and Urethral Diverticula

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

† Periurethral cysts and urethral diverticula imaging indications in pediatric members are identical to those for adult members. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-13: Periurethral Cysts and Urethral Diverticula for imaging guidelines.

PEDPV-10: Fetal MRI

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

† Fetal MRI indications in pediatric members are identical to those for adult members. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-15: Fetal MRI for imaging guidelines.

PEDPV-11: Undescended Testis

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

† Boys with a history of cryptorchidism (undescended testis) have a several-fold risk increase of testicular cancer. It is important to diagnose and treat this condition either by bringing the undescended testis into the scrotum, or resecting the testis.

† Pediatric-specific imaging considerations include the following:

† Suspected undescended testis is an indication for referral to a surgical subspecialist who should make the decision on necessary imaging studies.

† The following imaging is indicated for boys with suspected undescended testis based on a recent detailed physical exam.

® Scrotal ultrasound (CPT^® 76870) if testis not palpable in the scrotal sac and there is concern for retractile or inguinal testis,
¡ If ultrasound is inconclusive, either of the following may be approved:
■ MRI Abdomen (CPT^® 74183) and Pelvis (CPT^® 72197) without and with contrast, however MRI has a high false negative rate.
■ CT Abdomen and Pelvis with contrast (CPT^® 74177).

PEDPV-12: Scrotal Pathology

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

† Scrotal pathology imaging indications in pediatric members are very similar to those for adult members. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-20: Scrotal Pathology for imaging guidelines.

† Pediatric-specific imaging considerations include the following:

® Scrotal US (CPT^® 76870) with Doppler (CPT^® 93975 or CPT^® 93976) is indicated for concerns of testicular torsion.
® MRI is not typically used for the acute scrotum due to the limited availability of equipment and the long examination time involved. However, MRI Pelvis without (CPT^® 72195) or without and with (CPT^® 72197) contrast is indicated if torsion is unlikely on ultrasound and no surgical exploration is planned.
® Since the acceptance of Doppler US as the primary imaging for evaluation of acute scrotum, scintigraphy is not indicated. The unavailability of nuclear medicine imaging in many practices and its use of ionizing radiation, its poor anatomical details, and the time required for imaging are other limiting factors

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

† Penile soft tissue masses are very rare in pediatric members, and imaging indications are identical to those for adult members. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-18: Penis – Soft Tissue Mass for imaging guidelines.

PEDPV-14: Incontinence

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

† Incontinence imaging indications in pediatric members are very similar to those for adult members. See Adult Pelvis Imaging Policy (Policy #156 in the Radiology Section); PV-22: Incontinence/Pelvic Prolapse/Fecal Incontinence for imaging guidelines.

† Most often incontinence in children is not due to a medical condition. Several uncommon disorders that can lead to urinary incontinence include a spinal cord defect such as spina bifida, ureteral duplication with ectopic insertion, and overactive bladder or dysfunctional voiding.

† No imaging is needed if primary enuresis is suspected; however, imaging evaluation may be warranted if ureteral duplication or overactive bladder or dysfunctional voiding is suspected. The physician should obtain a full medical history and urinalysis before imaging is done.

† Radiopharmaceutical urinary bladder residual study (CPT^® 78730) is indicated for suspicion of urinary retention and a recent non-diagnostic ultrasound.

† Pediatric-specific imaging considerations include the following:

® MRI Pelvis without and with contrast (CPT^® 72197) is indicated if ultrasound is inconclusive or spinal abnormality is suspected.
® CT Pelvis with contrast (CPT^® 72193) is approvable if MRI is not readily available.

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

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

† Ultrasound pelvis (CPT^® 76856) is indicated as the initial evaluation for patent urachus.

® ANY of the following are indicated if the ultrasound is inconclusive or insufficient for preoperative planning:
¡ MRI Pelvis without contrast (CPT^® 72195)
¡ MRI Pelvis without and with contrast (CPT^® 72197)
¡ CT Pelvis with contrast (CPT^® 72193)

® New or worsening symptoms
® Preoperative planning

Ultrasound has an accuracy greater than 90%.

References
1. Villavicencio CP, Adam SZ, Nikolaidis P, Yaghmai V, Miller FH. Imaging of the Urachus: Anomalies, Complications, and Mimics. RadioGraphics. 2016;36(7):2049-2063. doi:10.1148/rg.2016160062.
2. Berrocal T, López-Pereira P, Arjonilla A, Gutiérrez J. Anomalies of the Distal Ureter, Bladder, and Urethra in Children: Embryologic, Radiologic, and Pathologic Features. RadioGraphics. 2002;22(5):1139-1164. doi:10.1148/radiographics.22.5.g02se101139.
3. Little DC, Shah SR, Peter SDS, et al. Urachal anomalies in children: the vanishing relevance of the preoperative voiding cystourethrogram. Journal of Pediatric Surgery. 2005;40(12):1874-1876. doi:10.1016/j.jpedsurg.2005.08.029.
4. Yiee JH, Garcia N, Baker LA, Barber R, Snodgrass WT, Wilcox DT. A diagnostic algorithm for urachal anomalies. Journal of Pediatric Urology. 2007;3(6):500-504. doi:10.1016/j.jpurol.2007.07.010.
5. Naiditch JA, Radhakrishnan J, Chin AC. Current diagnosis and management of urachal remnants. Journal of Pediatric Surgery. 2013;48(10):2148-2152. doi:10.1016/j.jpedsurg.2013.02.069.

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.

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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.

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

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*