Anthem Blue Cross ConnecticutCommercial Clinical Policy

CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography Form

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Non-Obstetrical Transvaginal Ultrasonography

Indications

(917867) Is the Non-Obstetrical Transvaginal Ultrasonography being performed to evaluate or guide treatment for abnormal uterine or vaginal bleeding? 
(917868) Is the procedure being used to assess amenorrhea, delayed menses, or dysmenorrhea? 
(917869) Is the procedure intended for evaluating congenital uterine or lower genital tract anomalies? 
(917870) Is the patient presenting with endometriomas or endometriosis, including deeply infiltrating endometriosis of the rectum or rectovaginal septum? 
(917871) Is the procedure being performed post pelvic surgery to investigate excessive bleeding, pain, or signs of infection? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses the use of non-obstetrical transvaginal ultrasonography for the evaluation of conditions of the pelvis and surrounding tissues.

Note: This document does not address the use of transvaginal ultrasonography for infertility-related conditions and treatments.

Clinical Indications

Medically Necessary:

  1. Non-obstetrical transvaginal ultrasonography is considered medically necessary to evaluate or guide treatment for any of the following conditions:
    1. Abnormal uterine or vaginal bleeding; or
    2. Amenorrhea, delayed menses, or dysmenorrhea; or
    3. Congenital uterine or lower genital tract anomalies; or
    4. Endometriomas or endometriosis, including deeply infiltrating endometriosis of the rectum or rectovaginal septum; or
    5. Excessive bleeding, pain, or signs of infection after pelvic surgery; or
    6. Follow-up of a previously detected abnormality of the pelvis or surrounding tissues; or
    7. Incontinence or pelvic organ prolapse; or
    8. New onset of symptoms such as abdominal or pelvic pain, bloating, early satiety, or urinary frequency and urgency, and an abnormal abdominal or pelvic examination is suspicious for gynecologic cancers; or
    9. Pelvic infection or pelvic inflammatory disease (such as, tubo-ovarian abscess, hydrosalpinx, or pyosalpinx); or
    10. Pelvic masses, benign or malignant (such as, adenomyosis, fibroids, cancers of the ovaries, vagina, uterus, or other pelvic structures); or
    11. Polycystic ovarian syndrome.
  2. Non-obstetrical transvaginal ultrasonography is considered medically necessary to monitor for endometrial or ovarian cancer in individuals with hereditary breast and ovarian cancer syndromes (HBOC), Lynch syndrome, or Peutz-Jeghers syndrome.
  3. Non-obstetrical transvaginal ultrasonography is considered medically necessary to confirm the position of an intrauterine contraceptive device if the device string is not visible or there is a suspicion that the device is incorrectly positioned within the uterus.

Not Medically Necessary:

Transvaginal ultrasonography is considered not medically necessary when criteria are not met and for all other indications, including routine screening for gynecologic cancers (such as, endometrial or ovarian cancer).