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MRI Pelvis - CAM 714HB

Description 

Pelvis Magnetic Resonance Imaging (MRI) generates images of the organs and structures within the pelvis without the use of ionizing radiation.

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: There is no MRI abdomen/pelvis combo (comparable to a CT abdomen/pelvis) such that if imaging of both the abdomen and pelvis are indicated, two separate exams (and authorization) are required (i.e., MRI abdomen and MRI pelvis) 

INDICATIONS FOR PELVIC MRI
Inflammatory Bowel Disease

  • For evaluation of Inflammatory Bowel Disease (IBD) such as Crohn’s or Ulcerative Colitis (includes MR Enterography)(1,2)
  • For suspected inflammatory bowel disease after complete work up including physical exam, labs, and recent colonoscopy
  • Known inflammatory bowel disease with recurrence or worsening signs/symptoms requiring re-evaluation or for monitoring therapy

Evaluation of Inflammation and Infection (3,4,5)
Fistula and Stricture

  • For history of fistula in the pelvis that requires re-evaluation or is suspected to have recurred
  • Suspected perianal fistula(6)
  • For patients with recurrent fistula or perianal Crohn’s disease(7)
  • 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 in the setting of a pelvic fracture)(8)

Known or Suspected Infection When CT is Contraindicated or Cannot Be Performed

  • Any known infection that is clinically suspected to have created an abscess in the pelvis
  • Abnormal fluid collection limited to the abdomen seen on prior imaging that needs follow-up evaluation
  • Suspected peritonitis when abdominal pain and tenderness to palpation are present, and at LEAST one of the following:(5)
  • Rebound, guarding or rigid abdomen, OR
  • Severe tenderness to palpation over the entire abdomen
  • Complications of diverticulitis (diagnosed either clinically or by imaging) with severe abdominal pain or severe tenderness or mass, not responding to antibiotic treatment)

Evaluation of Suspected/Known Hernia (9)

  • For pelvic pain due to a suspected occult, spigelian, or incisional hernia when physical exam and prior imaging (ultrasound AND CT) are non-diagnostic or equivocal and limited to the pelvis
  • Hernia with suspected complications, such as strangulation or incarceration, and CT is inconclusive, contraindicated or cannot be performed
  • Suspected athletic pubalgia (sports hernia) in a patient with persistent groin pain that occurs with exertion, who has not responded to conservative treatment for four weeks, when prior imaging (ultrasound or CT) is inconclusive
  • 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)

Musculoskeletal Indications

  • Initial evaluation of suspicious mass/tumor of the bones, muscles or soft tissues of the pelvis found on an imaging study, and needing clarification, or found by physical exam and after x-ray or ultrasound is completed
  • Evaluation of suspected fracture and/or injury when initial imaging is completed or for confirmed stress (fatigue) fracture for “return to play” evaluation(10)
  • For evaluation of known or suspected aseptic/avascular necrosis of hip(s) after completion of initial x-ray(11)
  • Known or suspected sacroiliitis (infectious or inflammatory) after completion of x-ray and rheumatologic workup(12)
  • Sacroiliac Joint Dysfunction (after initial X-ray) when there is:(13)
    • 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)
  • For evaluating the lumbosacral plexus:(14)
    • Confirm involvement in symptomatic patients with known tumor
    • Assess extent of injuries in the setting of pelvic trauma
    • Exclude the presence of masses in patients with unilateral changes, or inconclusive or abnormal findings on EMG when there are persistent symptoms
    • Evaluation when lumbar spine MRI is suspicious or indeterminate
  • Suspicion of pudendal neuralgia in the setting of chronic pelvic pain with genital numbness and erectile dysfunction when other causes have been ruled out (see Background regarding diagnosis)(15)
  • Suspicion of meralgia paresthetica when prior testing is inconclusive (diagnostic nerve block; electrodiagnostic testing; AND somatosensory evoked potentials)(16)
  • 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(17)
  • Evaluation of both hips when the patient meets hip MRI guidelines (x-ray + persistent pain unresponsive to conservative treatment) for both the right and left hip, Pelvis MRI is the preferred study.
    • If labral tear is suspected due to a positive anterior impingement sign or posterior impingement sign, then bilateral hip MRIs are the preferred studies (not Pelvis MRI)
    • If bilateral hip arthrograms are requested and otherwise meet guidelines, bilateral hip MRIs are the preferred studies (not Pelvis MRI)
  • For further evaluation of congenital anomalies of the sacrum and pelvis and initial imaging has been performed

Other Indications for Pelvic MRI

  • Pelvic pain when a gynecologic cause is suspected after initial imaging (ultrasound and/or CT) and laboratory evaluation has been completed(18)
  • Chronic pelvic pain syndrome
  • Location or evaluation of undescended testes in adults and in children, including determination of location of testes, if ordered by a specialist(19)
  • 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(18)
  • 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(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, such as the following:(23)
    • 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 enlargement
      • 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 diverticulum and other imaging (ultrasound) is inconclusive OR for surgical planning ORwith findings on exam or cystoscopy that are highly suggestive of urethral diverticulum (i.e., ostia on cystoscopy or tender cystic lesion on anterior vaginal wall overlying the urethra)(26)
  • Suspected pelvic congestion syndrome in women with chronic pelvic pain when other imaging is non-diagnostic(27)
  • Suspected patent urachus or other urachal abnormalities when ultrasound is non- diagnostic(28)
  • MR defecography for suspected structural cause of defecatory outlet obstruction to confirm diagnosis if other testing is equivocal (anorectal manometry and balloon expulsion testing)(29)
  • Evaluation of enlargement of organ abnormality seen on previous imaging - to provide an alternative to an indeterminate or inconclusive ultrasound
  • Transient or episodic hematospermia and age ≥ 40 with negative or inconclusive ultrasound
  • Persistent hematospermia (duration > 1 month, any age) with negative or inconclusive ultrasound(30)

When CT is Inconclusive, Contraindicated or Cannot be Completed

  • Persistent abdominal/pelvic pain after initial laboratory evaluation and either ultrasound and/or scope has been completed and does not reveal a cause
  • Fever of unknown origin (temperature of ≥ 101 degrees for a minimum of 3 weeks)

after standard diagnostic tests are negative (seeBackground)

  • Any B-symptoms of fevers more than 101◦ F, drenching night sweats, or unexplained weight loss of more than 10% of body weight over 6 months with documented concern for lymphoma/malignancy(31)
  • Weight loss:
    • Clinically significant unintentional weight loss i.e., ≥5% of body weight in less than 12 months (or ≥2% in one month), with signs or symptoms suggestive of an abdominal or pelvic cause (see Background) OR
    • Ongoing unexplained clinically significant weight loss i.e., ≥5% of body weight in less than 12 months (or ≥ 2% in one month)(32) after initial workup (see Background) has been completed, no cause identified, and second visit documenting further decline in weight(33)
  • Suspected or known retroperitoneal fibrosis after complete workup and ultrasound to determine extent of disease(34)
  • Suspected paraneoplastic syndrome (including dermatomyositis) with high suspicion of abdominal malignancy and appropriate workup has been done (see Background for details) 
  • Diffuse, unexplained lower extremity edema with negative or inconclusive ultrasound(35)
  • Suspected May-Thurner syndrome (CTV/MRV preferred)(36)
  • Further evaluation of a new onset or non-reducible varicocele(37)
  • Prior to Bone Marrow Transplant (BMT)(38, 39)
  • Follow-up of abnormal lymph nodes with no prior history of malignancy
    • Follow-up imaging at 3 months(40)

Suspected Malignancy
Suspected Prostate Cancer (41,42,43,44,45,46)
Prior to prostate biopsy when notes indicate that biopsy is planned(47)

  • In individuals with previous negative biopsy and ongoing concerns of increased risk of prostate cancer (i.e., rising or persistently elevated PSA OR suspicious digital rectal exam (DRE))
  • For evaluation of elevated PSA (on two separate levels) when PI-RADS classification needed to make decision on whether or not to perform a biopsy when ALL of the following has been provided:(48)
    • Digital rectal examination (DRE) findings
    • PSA elevation not attributed to benign disease
    • Biopsy has been discussed with the patient (Typically, this request would be from the person performing the biopsy (i.e., urologist) and imaging done at the facility where the fusion biopsy would be performed should a higher risk lesion be identified.)
  • For evaluation of a very suspicious prostate nodule on exam when biopsy is under consideration(48)
  • Follow up MRI can be approved at the following intervals:(49,50)
    • PI-RADS 3-5 lesions: 12-month interval
    • PI-RADS 1-2 lesions: 24-month interval
      • Earlier for PI-RADS 1-2 if biopsy is clearly planned, progressive rise in PSA or other risk factors exist

Known Malignancy
Initial Staging

  • Pelvis MRI is indicated (if not previously done) for the following malignancies:
  • Anal Carcinoma
  • Cervical Cancer
  • Gestational Trophoblastic Neoplasia
  • Ovarian Cancer
  • Pediatric Solid Tumors
  • Prostate Cancer
  • Rectal Cancer
  • Uterine Neoplasms
  • Vulvar Cancer
  • For all other malignancies, Pelvis MRI is indicated to clarify indeterminate findings on CT

Restaging (51)

  • Pelvis MRI is indicated for restaging during active treatment (every 2-3 cycles of chemo or immunotherapy, following radiation and/or after surgery) for the following malignancies:
    • Prostate Cancer:
      • Annually if on active surveillance
      • When recurrence is suspected and PSMA PET is not planned (see CG_070-1 PET for further detail)
    • Rectal Cancer

Surveillance (52)

  • Pelvis MRI is not typically used during surveillance, however, for the cancers listed above, can be considered on a case to case basis OR when CT is contraindicated and cannot be performed

Pre-operative Evaluation

  • For diagnostic purposes prior to pelvic surgery or procedure

Post-Operative/Procedural Evaluation
When not otherwise addressed in the guideline

  • Follow-up of known or suspected post-operative complication (within 6 months) involving the hips or the pelvis (53)
  • 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.

Genetic Syndromes and Rare Diseases
Surveillance Screening Pelvis MRI for the following KNOWN Genetic Syndromes

  • FAP (Familial Adenomatous Polyposis, annual screening of abdomen and pelvis with MRI or CT for one or more of the following: personal history of desmoid tumor, family history of desmoid tumor or abdominal symptoms suggestive of desmoid tumor(54)
  • PGL/PCC (Hereditary Paraganglioma/Pheochromocytoma syndromes or SDHx mutations): every 2 years IF whole body MRI (unlisted MRI CPT 76498) NOT available (55) (see CG_063 Unlisted Studies)
  • Multiple Endocrine Neoplasia type 1 (MEN1): annually(56)
  • For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance.

Combination Studies
Abdomen/Pelvis MRI

  • As a dedicated CPT code does not exists for Abdomen and Pelvis MRI (unlike CT), when a disease process is reasonably expected to involve both the abdomen and pelvis AND the guideline criteria have been met, two separate authorizations are required: Abdomen MRI (CPT 74181, 74182, 74183) and Pelvis MRI (CPT 72195, 72196, 72197).

Brain/Chest/Abdomen/Pelvis MRI

  • Multiple Endocrine Neoplasia Syndrome Type 1 (MEN-1)
    • Chest/Abdomen/Pelvis annually
    • Brain/Chest/Abdomen/Pelvis every 3 years

Neck/Abdomen/Pelvis MRI and Chest CT

  • PGL/PCC (Hereditary Paraganglioma/Pheochromocytoma syndromes or SDHx mutations): every 2 years IF whole body MRI (unlisted MRI CPT 76498) not available (55) (see Unlisted Studies Evolent_CG_063)(57)

Pelvis MRI and Pelvis MRA

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

Pelvis MRI and Fetal MRI

  • When medical necessity has been met for Pelvis MRI (such as for suspected placenta accreta or percreta when ultrasound is indeterminate(24) AND medical necessity has been met for Fetal MRI (such as suspected fetal abnormality after ultrasound has been performed), two separate authorizations are required: Pelvis MRI (CPT 72195) and Fetal MRI (CPT 74712).

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 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
PI-RADS Assessment Categories for Prostate Cancer
The assignment of a PI-RADS category is based on mpMRI findings only and does not incorporate other factors, including PSA testing, DRE (digital rectal exam), or clinical history.

  • PI-RADS 1 – Very low (clinically significant cancer is highly unlikely to be present)
  • PI-RADS 2 – Low (clinically significant cancer is unlikely to be present)
  • PI-RADS 3 – Intermediate (the presence of clinically significant cancer is equivocal)
  • PI-RADS 4 – High (clinically significant cancer is likely to be present)
  • PI-RADS 5 – Very high (clinically significant cancer is highly likely to be present)

*Conservative Therapy
Conservative therapy 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.

MRI and Lumbosacral Plexopathy
Complete lumbar (L1-L4) or sacral plexopathy (L5-S3) may present with weakness, sensory loss, and flaccid loss of tendon reflexes. Clinical diagnosis is confirmed by EMG. Acute and chronic plexopathies may be caused by nerve sheath tumors; infectious, autoimmune, hereditary, or idiopathic neuropathies; extrinsic compression; or trauma. There is no CPT® code specifically for imaging of the LS plexus.

Pudendal neuralgia may be considered in chronic pain patients who meet the Nantes criteria: pain in the area innervated by the pudendal nerve, pain more severe with sitting, pain that does not awaken the patient from sleep, pain with no objective sensory impairment, and pain relieved by pudendal block. All five criteria must be met for diagnosis.

Elevated CA-125 and Pelvic Imaging
There is no evidence that isolated levels of CA-125 with no other clinical or radiologic evidence of pathology is sensitive or specific and should not be performed as an isolated test as it can lead to unnecessary studies and anxiety. It is elevated in most cases of epithelial ovarian cancer and is used in monitoring response to treatment as an adjunct to pelvic US. CA-125 has been shown to be increased in many conditions such as fibroids, adenomyosis, pancreatic cancer, endometriosis, tuberculosis, and interstitial lung disease. MRI is not indicated as a first-line test.

Fever of Unknown Origin
Initial work up prior to CT would include a comprehensive history, repeated physical exam, complete blood count with differential, three sets of blood cultures, chest x-ray, complete metabolic panel, urinalysis, ESR, ANA, RA, CMV IgM antibodies, virus detection in blood, heterophile antibody test, tuberculin test, and HIV antibody test. Lastly, with a negative CXR, only when initial workup and abdomen/pelvis CT/MR fail to identify the cause for fever can

Chest CT be approved. If CXR suggests a malignancy and/or source of fever, then Chest CT would be approved.

Paraneoplastic Syndromes
Suspected paraneoplastic syndromes with no established cancer diagnosis: laboratory evaluation and imaging the laboratory evaluation for paraneoplastic syndrome is complex. If the appropriate lab test results are suspicious for malignancy, imaging is indicated.

For SIADH (hyponatremia + increased urine osmolality), there is a high association with small cell lung cancer, therefore imaging typically starts with chest CT. If other symptoms suggest a different diagnosis other than small cell lung cancer, different imaging studies may be reasonable.

For hypercalcemia (high serum calcium, low-normal PTH, high PTHrP) it is reasonable to start with bone imaging followed by a more directed evaluation such as mammogram, chest, abdomen and pelvis imaging as appropriate.

For Cushing syndrome (hypokalemia, normal-high midnight serum ACTH NOT suppressed with dexamethasone) abdominal and chest imaging is reasonable. If dexamethasone suppression test DOES suppress ACTH, pituitary MRI is reasonable.

For hypoglycemia, labs drawn during a period of hypoglycemia (glucose < 55, typically a 72 hour fast) (insulin level, C-peptide and IGF-2:IGF-1 ratio) should be done to evaluate for an insulinoma. An elevated insulin level, elevated C-peptide and/or normal IGF-2:IGF-1 ratio warrants CT or MRI abdomen to look for insulinoma. A low insulin, low C-peptide and/or elevated IGF-2:IGF-1 ratio warrants chest and abdominal imaging.

When a paraneoplastic neurologic syndrome is suspected, nuclear and cytoplasmic antibody panels are often ordered to further identify specific tumor types. Results are needed prior to imaging. Because these tests are highly specific, if an antibody highly associated with a specific cancer is positive, then further imaging for that cancer is reasonable. For example, anti-Hu has a high association with SCLC and chest CT would be reasonable.
Anti-MA2 has a high association with testicular cancer and testicular ultrasound would be a reasonable next step.


Weight Loss
Unintentional weight loss is considered clinically significant if the amount of weight lost over 12 months is ≥ 5%. Older age and higher percentage of weight loss correlates with higher likelihood of malignancy. A targeted evaluation is recommended when there are signs or symptoms suggestive of a specific source. For example, when there is clinically significant weight loss with abdominal pain that prompts an evaluation for an abdominal source of the weight loss; CXR and labs such as TSH would not be needed prior to abdominal imaging. Conversely a smoker with a cough and weight loss would not start with abdominal imaging, a chest x-ray (CXR) would be the first test to start with. When there is no suspected diagnosis, initial evaluation includes CXR, age-appropriate cancer screening (such as colonoscopy and mammography) and labs (including CBC, CMP, HbA1C, TSH, stool hemoccult, ESR/CRP, HIV, Hepatitis C). If this initial evaluation fails to identify a cause of weight loss, then the patient is monitored and if progressive weight loss is seen on subsequent visits/weights, then CT Abdomen/Pelvis is reasonable (MRI if there is a contraindication to CT such as contrast allergy or impaired renal function). Lastly, with a negative CXR, only when initial workup and abdomen/pelvis CT/MR fail to identify the cause for weight loss can Chest CT be approved. If CXR suggests a malignancy and/or source of weight loss, then Chest CT would be approved.

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 

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Coding Section 

Codes

Number

Description

CPT

72195

Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s)

 

72196

with contrast material(s)

 

72197

without contrast material(s), followed by contrast material(s) and further sequences
  0698T

Annual review, updating entire policy. Adding general information statement and evaluation of indeterminate findings on prior imaging. Clarifying pathological reflexes and cerebellar ataxia. Removing radicular pain and malaise from isolated back pain in pediatric population.

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 

12/02/2024 Annual review, updating policy for clarity and consistency including uses of fetal MRI and Pelvis MRI, gynecologic uses updated, prostate cancer, known malignancies and inflammation/infections sections reorganized. Genetic and rare disease section added and combination studies updated.  Also updating rationale and references.
01/01/2024 New Policy
Complementary Content
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