Anthem Blue Cross Connecticut CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography Form

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).