Anthem Blue Cross Connecticut CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting Form

This document addresses the use of duplex ultrasonography, in the outpatient, gynecologic setting, for the evaluation of conditions of the pelvis and surrounding tissues. A duplex ultrasound is a procedure used to visualize the pattern and direction of blood flow in arteries and veins via real-time images. This document does not address duplex ultrasonography for obstetric indications or infertility-related conditions and treatments.

Note: Please see the following related document(s) for additional information:

• CG-MED-42 Maternity Ultrasound in the Outpatient Setting
• CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography

Clinical Indications

Medically Necessary:

Non-obstetric, gynecologic, duplex ultrasonography of the abdomen or pelvis, in the outpatient setting, is considered medically necessary when there is a documented health history and physical examination findings that indicate visualization of vascular characteristics is necessary, including but not limited to evaluation or suspicion of the following conditions:

1. Abnormal uterine bleeding; or
2. Endometrial polyps; or
3. Endometriomas; or
4. Neoplasm; or
5. Ovarian or adnexal cysts; or
6. Ovarian torsion; or
7. Pelvic congestion syndrome; or
8. Polycystic ovarian syndrome; or
9. Vascular diseases affecting the pelvic organs (for example, arteriovenous malformations and aneurysms).

Not Medically Necessary:

Non-obstetric, gynecologic, duplex ultrasonography of the abdomen or pelvis, in the outpatient setting, is not medically necessary when the criteria above are not met and for all other indications, including but not limited to:

1. Routine screening in asymptomatic individuals*;
2. Repeat evaluation in the absence of a change, or to assess a suspected change, in previously documented health exam findings.

*The term “individual” in this document refers to any person with female reproductive and genitourinary systems, regardless of gender identity.