Description
Pelvis Computed Tomography (CT) uses radiation to generate images of the organs and structures in the pelvis. Pelvic imaging begins at the umbilicus or iliac crests and extends to the level of the lesser trochanters.
 

General Information

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy
Note: For syndromes for which imaging starts in the pediatric age group, MRI preferred

Note: PELVIS CT ALONE SHOULD ONLY BE APPROVED WHEN DISEASE PROCESS IS SUSPECTED TO BE LIMITED TO THE PELVIS. CT abdomen/pelvis combo (CPT codes 74176, 74177, 74178) is the correct study when the indication(s) include both the abdomen AND pelvis, such as CTU (CT urography), CTE (CT enterography), acute abdominal pain, widespread inflammatory disease or neoplasm.

When separate requests for CT abdomen and CT pelvis are encountered for processes involving both the abdomen and pelvis, they need to be resubmitted as a single Abdomen/Pelvis CT (to avoid unbundling). Otherwise, the exam should be limited to the appropriate area (i.e., abdomen OR pelvis) which includes the specific organ, area of known disease/abnormality, or the area of concern.

INDICATIONS FOR PELVIS CT
Pelvic Pain for Unknown Etiology

• CT allowed after initial workup is inconclusive and must include results of the following:⁽¹⁾
  • Initial imaging, such as ultrasound, scope study, or x-ray AND
  • Appropriate laboratory testing (chemistry profile, complete blood count, and urinalysis)

• For acute pelvic pain in a patient over the age of 65⁽²⁾

Evaluation of Inflammation and Infection (3,4)

• Fistula
  • Suspected perianal fistula or occult anorectal abscess⁽⁵⁾
  • For patients with recurrentfistula in anal or perianal Crohn’s disease when MRI is contraindicated or cannot be performed⁽⁶⁾
  • Any history of fistula limited to the pelvis that requires re-evaluation or is suspected to have recurred
• Infection
  • Suspected infection in the pelvis (based on elevated WBC, fever, anorexia, or nausea and vomiting)
  • Complications of diverticulitis limited to the pelvis (prior imaging study is not required for diverticulitis diagnosis) with severe abdominal pain or severe tenderness or mass, not responding to antibiotic treatment
  • Any known infection to have created an abscess in the pelvis that requires re- evaluation
• Stricture
  • Suspected urethral stricture or periurethral pathology after initial evaluation with cystoscopy or urethroscopy and additional imaging is needed (such as for suspected malignancy, diverticula, fistula or extensive fibrosis OR for preoperative planning)
• Fluid Collection
  • Abnormal fluid collection seen on prior imaging that needs follow-up evaluation and limited to the pelvis

Suspected or Known Hernia (7)

• For pelvic pain due to a suspected occult, spigelian, or incisional hernia when physical exam and prior imaging are non-diagnostic or equivocal or if requested as a preoperative study
• For confirming the diagnosis of a recurrent hernia when ultrasound is negative or non-diagnostic
• Hernia with suspected complications (e.g., bowel obstruction or strangulation, or non- reducible) based on symptoms (e.g., diarrhea, hematochezia, vomiting, severe pain), physical exam (guarding, rebound) or prior imaging

• Deep pelvic hernia is suspected (obturator, sciatic or perineal); does not require US first but this type of hernia needs to be specified in notes (if CT Abdomen is also needed, resubmit as CT Abdomen and Pelvis)

Musculoskeletal Indications
When MRI is Contraindicated or Cannot Be Performed

• Known or suspected aseptic/avascular necrosis of hip(s) after completion of initial x- ray⁽⁸⁾ (CT or MRI can be approved for surgical planning)
• Sacroiliitis (infectious or inflammatory, such as Ankylosing Spondylitis/Spondyloarthropathies) after completion of x-ray and rheumatology workup⁽⁹⁾
• Sacroiliac joint dysfunction (after initial x-ray) when there is:⁽¹⁰⁾
  • Persistent back and/or sacral pain unresponsive to four (4) weeks of conservative treatment, received within the past six (6) months, including physical therapy or physician-supervised home exercise plan (HEP)
• Persistent Pain:
  • Evaluation of persistent pain unresponsive to four (4) weeks of conservative treatment received within the past six (6) months
  • Suspected piriformis syndrome after failure of 4 weeks conservative treatment⁽¹¹⁾
• Evaluation of both hips when the patient meets hip CT guidelines (x-ray + persistent pain unresponsive to conservative treatment) for both the right and left hip, Pelvis CT is the preferred study
  • If labral tear is suspected due to a positive anterior impingement sign or posterior impingement sign, then bilateral hip CTs are the preferred studies (not Pelvis CT)
  • If bilateral hip arthrograms are requested and otherwise meet guidelines, bilateral hip MRIs are the preferred studies (not Pelvis CT)
• When non-diagnostic imaging is requested for anatomic guidance for hip surgery, a CT Pelvis is approvable since measurements of both hips may be needed (only one non-diagnostic request can be approved and should include the surgical site)
• Further evaluation of congenital anomalies of the sacrum and pelvis after initial imaging has been performed
• Evaluation of physical or radiological evidence of complex or occult pelvic fracture or for pre-operative planning of complex pelvic fractures

Other Indications

• Persistent pelvic pain not explained by previous imaging

• Diffuse, unexplained lower extremity edema with negative or inconclusive ultrasound⁽¹²⁾
• Suspected May-Thurner syndrome (CTV/MRV preferred)⁽¹³⁾
• Further evaluation of a new onset or non-reducible varicocele⁽¹⁴⁾
• Assessment of pelvic congestion syndrome when findings on ultrasound are indeterminate (CTA/MRA preferred)⁽¹⁵⁾
• To locate an intrauterine device after ultrasound and plain x-ray are equivocal or non- diagnostic (imaging of the abdomen may also be indicated)⁽¹⁶⁾
• Diagnosis or to guide treatment of urachal anomalies when ultrasound is non- diagnostic⁽¹⁷⁾
• Prior to solid organ transplantation

When MRI is Contraindicated or Cannot Be Performed

• Follow-up of an indeterminate or inconclusive finding on ultrasound limited to the pelvis
• Location or evaluation of undescended testes in adults and in children, including determination of location of testes, if ordered by a specialist⁽¹⁸⁾
• Evaluation and characterization of uterine and adnexal masses, (e.g., fibroids, ovaries, tubes, and uterine ligaments) or congenital uterine or renal abnormality where ultrasound has been done previously⁽¹⁹⁾
• Evaluation of abnormal uterine bleeding when ultrasound findings are indeterminate⁽²⁰⁾
  • Age ≤ 50 – Vascular stalk or focal doppler signal on US
  • Age > 50 – Thickened endometrium, vascular stalk or focal doppler signal on US
• Evaluation of uterus prior to and after embolization (CTA may be approved in addition to CT for preprocedural planning)⁽²¹⁾
• Evaluation of endometriosis when preliminary imaging has been completed or to follow up known endometriosis⁽²²⁾
• Further evaluation of suspected adenomyosis when ultrasound is inconclusive,⁽²³⁾ such as the following:
• • Uterine abnormality on US
    • Anechoic spaces/cysts in myometrium
    • Heterogeneous echotexture
    • Obscured endometrial/myometrial border
    • Sub-endometrial echogenic linear striations
    • Thickening of the transition zone

• • • Uterine wall thickening
• Prior to uterine surgery if there is abnormality suspected on prior ultrasound
• Suspected placenta accreta or percreta when ultrasound is indeterminate⁽²⁴⁾
• Further assessment of a scrotal or penile mass when ultrasound is inconclusive⁽²⁵⁾
• Investigation of a malfunctioning penile prosthesis
• Suspected urethral diverticula and other imaging is inconclusive⁽²⁶⁾
• Suspected patent urachus or other urachal abnormalities when ultrasound is non- diagnostic⁽¹⁷⁾
• Transient or episodic hematospermia and age ≥ 40 with negative or inconclusive ultrasound
• Persistent hematospermia (duration > 1 month, any age) with negative or inconclusive ultrasound⁽²⁷⁾

Evaluation of Known or Suspected Non-Aortic Vascular Disease

• Follow-up for post-endovascular repair (EVAR) or open repair of iliac artery aneurysms (28,29,30)
  • Routine, baseline study (post-op/intervention) after EVAR:
    • Within the first month of the procedure
    • Continued follow-up at the following intervals:
      • If no endoleak or sac enlargement is seen:
        • Annually monitor with ultrasound
          • When US is abnormal or insufficient CT/MR can be used to monitor annually
        • Every 5 years monitor with CT/MR
      • If type II endoleak is seen at any point in time:
        • Every 6 months x 2 years, then annually (does not require US)
• If symptomatic or imaging shows increasing, or new findings related to stent graft – more frequent imaging may be needed

Evaluation of Suspicious or Known Mass/Tumors

• Initial evaluation of suspicious pelvic masses/tumors found only in the pelvis by physical exam and ultrasound has been performed

• Surveillance: One follow-up exam to ensure no suspicious change has occurred in a tumor in the pelvis. No further surveillance CT unless tumor(s) are specified as highly suspicious, or change was found on exam or last follow-up imaging
• For abnormal incidental pelvic lymph nodes when follow-up is recommended based on prior imaging (initial 3-month follow-up)⁽³¹⁾

Pre-Operative Evaluation

• For diagnostic purposes prior to pelvic surgery or procedure

Post-Operative/Procedural Evaluation

• Follow-up of known or suspected post-operative complication involving the hips or the pelvis⁽³²⁾ within six months
• A follow-up study to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed

Combination Studies
Pelvis CTA (or MRA) and Pelvis CT

• When needed for clarification of vascular invasion from tumor (including suspected renal vein thrombosis)
• Prior to uterine artery embolization for fibroids

Combination Studies for Malignancy for Initial Staging or Restaging
Unless otherwise specified in this guideline, indication for combination studies for malignancy for initial staging or restaging:

• Concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Abdomen, Brain, Chest Neck, Pelvis, Cervical Spine, Thoracic Spine or Lumbar Spine.

Further Evaluation of Indeterminate Findings on Prior Imaging
Unless follow-up is otherwise specified within the guideline

• For initial evaluation of an inconclusive finding on a prior imaging report (i.e., x-ray, ultrasound or CT) that requires further clarification
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam.)

Rationale
*Conservative Therapy
This should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections (epidural, facet, bursal, and/or joint, not including trigger point), and diathermy can be utilized. Active modalities may consist of physical therapy, a physician-supervised home exercise program**, and/or chiropractic care.

**Home Exercise Program (HEP)
The following elements are required to meet guidelines for completion of conservative therapy:

• Information provided on exercise prescription/plan AND

• Follow-up with member with documentation provided regarding lack of improvement (failed) after completion of HEP (after suitable 4-week period), or inability to complete HEP due to physical reason- i.e., increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without explanation does not constitute “inability to complete” HEP).
• Dates and duration of failed PT, physician-supervised HEP, or chiropractic treatment should be documented in the original office notes or an addendum to the notes.

Contraindications and Preferred Studies

• Contraindications and reasons why a CT/CTA cannot be performed may include impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester)
• Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non- compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine

References

1. Brook O R, Dadour J R, Robbins J B, Wasnik A P, Akin E A et al. ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update. Journal of the American College of Radiology. 2024; 21: S3 - S20. 10.1016/j.jacr.2024.02.014.
2. Henrichsen T L, Maturen K E, Robbins J B, Akin E A, Ascher S M et al. ACR Appropriateness Criteria® Postmenopausal Acute Pelvic Pain. Journal of the American College of Radiology. 2021; 18: S119 - S125. 10.1016/j.jacr.2021.02.003.
3. Cartwright S, Knudson M. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. Apr 1, 2015; 91: 452-9.
4. Frickenstein A N, Jones M A, Behkam B, McNally L R. Imaging Inflammation and Infection in the Gastrointestinal Tract. International journal of molecular sciences. 2019; 21: 10.3390/ijms21010243.
5. Levy A D, Liu P S, Kim D H, Fowler K J, Bharucha A E et al. ACR Appropriateness Criteria® Anorectal Disease. Journal of the American College of Radiology. 2021; 18: S268 - S282. 10.1016/j.jacr.2021.08.009.
6. Steinhart A H, Panaccione R, Targownik L, Bressler B, Khanna R et al. Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohns Disease: The Toronto Consensus. Inflammatory bowel diseases. 2019; 25: 1-13. 10.1093/ibd/izy247.
7. Garcia E M, Pietryga J A, Kim D H, Fowler K J, Chang K J et al. ACR Appropriateness Criteria® Hernia. Journal of the American College of Radiology. 2022; 19: S329 - S340. 10.1016/j.jacr.2022.09.016.
8. Ha A S, Chang E Y, Bartolotta R J, Bucknor M D, Chen K C et al. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. Journal of the American College of Radiology. 2022; 19: S409 - S416. 10.1016/j.jacr.2022.09.009.
9. Czuczman G J, Mandell J C, Wessell D E, Lenchik L, Ahlawat S et al. ACR Appropriateness Criteria® Inflammatory Back Pain: Known or Suspected Axial Spondyloarthritis: 2021 Update. Journal of the American College of Radiology. 2021; 18: S340 - S360. 10.1016/j.jacr.2021.08.003.
10. Falowski S, Sayed D, Pope J, Patterson D, Fishman M et al. A Review and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain. Journal of pain research. 2020; 13: 3337-3348. 10.2147/JPR.S279390.
11. Hicks B L, Lam J C, Varacallo M. Piriformis Syndrome [Updated 2023 Aug 4]. StatPearls Publishing (Internet). 2023; Accessed May 2024:
12. Gasparis A P, Kim P S, Dean S M, Khilnani N M, Labropoulos N. Diagnostic approach to lower limb edema. Phlebology. 2020; 35: 650-655. 10.1177/0268355520938283.
13. Knuttinen M, Naidu S, Oklu R, Kriegshauser S, Eversman W et al. May-Thurner: diagnosis and endovascular management. Cardiovascular diagnosis and therapy. 2017; 7: S159-S164. 10.21037/cdt.2017.10.14.
14. Schlegel P, Sigman M, Collura B, De Jonge C, Eisenberg M et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I. J Urol. Jan 2021; 205: 36-43. 10.1097/ju.0000000000001521.
15. Bookwalter C, VanBuren W, Neisen M, Bjarnason H. Imaging Appearance and Nonsurgical Management of Pelvic Venous Congestion Syndrome. Radiographics. Mar-Apr 2019; 39: 596-608. 10.1148/rg.2019180159.
16. Verstraeten V, Vossaert K, Van den Bosch T. Migration of Intra-Uterine Devices. Open access journal of contraception. 2024; 15: 41-47. 10.2147/OAJC.S458156. 

17. Briggs K B, Rentea R M. Patent Urachus [Updated 2023 Apr 10]. StatPearls Publishing [Internet]. 2023; Accessed May 2024:
18. Kolon T, Herndon C, Baker L, Baskin L, Baxter C et al. Evaluation and treatment of cryptorchidism: AUA guideline. J Urol. Aug 2014; 192: 337-45. 10.1016/j.juro.2014.05.005.
19. Brook O , Dadour J, Robbins J, Wasnik A, Akin E et al. ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group. American College of Radiology®. 2023; 2022:
20. Robbins J B, Sadowski E A, Maturen K E, Akin E A, Ascher S M et al. ACR Appropriateness Criteria® Abnormal Uterine Bleeding. Journal of the American College of Radiology. 2020; 17: S336 - S345. 10.1016/j.jacr.2020.09.008.
21. Kubik-Huch R A, Weston M, Nougaret S, Leonhardt H, Thomassin-Naggara I et al. European Society of Urogenital Radiology (ESUR) Guidelines: MR Imaging of Leiomyomas. European radiology. 2018; 28: 3125-3137. 10.1007/s00330-017-5157-5.
22. Wall D J, Reinhold C, Akin E A, Ascher S M, Brook O R et al. ACR Appropriateness Criteria® Female Infertility. Journal of the American College of Radiology. 2020; 17: S113 - S124. 10.1016/j.jacr.2020.01.018.
23. Cunningham R, Horrow M, Smith R, Springer J. Adenomyosis: A Sonographic Diagnosis. Radiographics. Sep-Oct 2018; 38: 1576-1589. 10.1148/rg.2018180080.
24. Kilcoyne A, Shenoy-Bhangle A, Roberts D, Sisodia R, Gervais D. MRI of Placenta Accreta, Placenta Increta, and Placenta Percreta: Pearls and Pitfalls. AJR Am J Roentgenol. Jan 2017; 208: 214-221. 10.2214/ajr.16.16281.
25. Parker R 3, Menias C, Quazi R, Hara A, Verma S et al. MR Imaging of the Penis and Scrotum. Radiographics. Jul-Aug 2015; 35: 1033-50. 10.1148/rg.2015140161.
26. Greiman A K, Rolef J, Rovner E S. Urethral diverticulum: A systematic review. Arab journal of urology. 2019; 17: 49-57. 10.1080/2090598X.2019.1589748.
27. Hosseinzadeh K, Oto A, Allen B, Coakley F, Friedman B et al. ACR Appropriateness Criteria(®) Hematospermia. J Am Coll Radiol. May 2017; 14: S154-s159. 10.1016/j.jacr.2017.02.023.
28. Chaikof E L, Dalman R L, Eskandari M K, Jackson B M, Lee W A et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. Journal of vascular surgery. 2018; 67: 2-77.e2. 10.1016/j.jvs.2017.10.044.
29. Isselbacher E M, Preventza O, Hamilton Black Iii J, Augoustides J G, Beck A W et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2022; 80: e223-e393. 10.1016/j.jacc.2022.08.004.
30. Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M et al. European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. European journal of vascular and endovascular surgery : the official journal of. 2019; 57: 8-93. 10.1016/j.ejvs.2018.09.020.
31. Bjurlin M A, Carroll P R, Eggener S, Fulgham P F, Margolis D J et al. Update of the Standard Operating Procedure on the Use of Multiparametric Magnetic Resonance Imaging for the Diagnosis, Staging and Management of Prostate Cancer. J Urol. 2020; 203: 706-712. 10.1097/ju.0000000000000617.
32. Davis D, Morrison J. Hip Arthroplasty Pseudo tumors: Pathogenesis, Imaging, and Clinical Decision Making. J Clin Imaging Sci. 2016; 6: 17. 10.4103/2156-7514.181493.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward