MRI (Magnetic Resonance Imaging) of the Pelvis Form

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MRI (Magnetic Resonance Imaging) of the Pelvis
Medical Guideline

Service: MRI (Magnetic Resonance Imaging) of the Pelvis

PUM 250-0062-1812

Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026

Related Medical Guidelines:

• MRI (Magnetic Resonance Imaging) of the Abdomen Medical Guideline

Description:

MRI of the Pelvis can be used for diagnosis, evaluation, assessment of severity, and follow-up of diseases of the male and female pelvic organs (rectum, prostate and genitourinary system) and avoids exposing the patient to ionizing radiation. MRI Pelvis is also used for further evaluation of indeterminate or questionable findings, identified on standard imaging exams (such as Ultrasound [US] and Computed Tomography [CT]).

For purposes of this guideline, there is no MRI Abdomen/Pelvis as there is CT Abdomen/Pelvis. If imaging of both the abdomen and pelvis are indicated, two separate exams (and authorizations) are required (i.e., MRI Abdomen and MRI Pelvis).

Indications of Coverage:

A Pelvis MRI is considered medically necessary for ANY of the following indications, when at least ONE of the additional criteria noted are met:

A. Initial staging of cancer (other than Prostate, addressed in C.)

B. Follow-up of known cancer:

1. Patient undergoing active treatment within the past year or as per

   surveillance imaging guidance for that cancer as per NCCN.

2. Suspected pelvic metastasis based on a sign/symptom or an abnormal lab value.

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C. Staging of prostate cancer, initial pelvic imaging (if not recently performed for biopsy planning) with either unfavorable intermediate or high or very high risk groups, as defined by NCCN.

D. Workup for recurrence of known prostate cancer and response to treatment:

1. Initial treatment by active surveillance
   o Initial multiparametric MRI (mpMRI) for patients who chose active surveillance. o mpMRI to be repeated no more than every 12 months unless clinical indicated.
2. Initial treatment by radical prostatectomy:
   o Failure of PSA to fall to undetectable level after surgery or
   o PSA level rising on at least 2 subsequent determinations.

3. Initial treatment radiation therapy:
   o Post-radiation therapy (Post-RT) rising PSA on at least 2 subsequent determinations or
   o positive digital exam and is candidate for local therapy.

   E. Prostate MRI for suspected prostate cancer is considered medically necessary

   if at least ONE of the following criteria is met:

4. With anatomic guidance needed for biopsy. Please note that for MRI fusion biopsy of prostate with transrectal US (MRI/TRUS), a repeat MRI subsequent to the MRI that detected the nodule is considered not medically necessary. *Please refer to 3D Rendering MRI/US/CT Medical Guideline as 3D reconstruction for this procedure would be considered medically necessary.
5. Ongoing concerns of increased risk of prostate cancer (i.e., rising or persistently elevated PSA OR suspicious digital rectal exam [DRE]).
6. Evaluation of elevated PSA on two occasions and MRI will impact decision-making as to whether or not biopsy will be performed.

7. Evaluation of a very suspicious prostate nodule on exam when biopsy is under consideration.

   F. Pelvis MRI for evaluation or follow-up of cancer is considered medically

   necessary for ANY of the below:

8. Combination studies are needed for initial pre-therapy staging of cancer.

9. Active monitoring for recurrence as clinically indicated by change on exam or suspicious change on most recent follow-up imaging or

   suspicious change in tumor markers/labs.

10. Evaluation of suspected metastases.

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4. Other evaluation or follow up of cancer consistent with NCCN guidelines for the cancer type.

   G. Evaluation of masses seen on ultrasound or CT for further evaluation of

   indeterminate or questionable findings:

5. Initial imaging
6. One follow-up exam to ensure no suspicious change has occurred in a tumor in the pelvis. No further surveillance MR unless tumor(s) is/are specified as highly suspicious, or change was found on exam or last follow-up imaging.

7. Abnormal incidental pelvic lymph nodes when follow-up is recommended based on prior imaging (initial 3-month follow-up).

   H. Evaluation of suspected infection or inflammatory disease with

   preliminary imaging (CT, US, or nuclear medicine) either being

   contraindicated or having been completed, but further characterization is

   clinically required:

8. Suspected perianal fistula.
9. Suspected infection (based on elevated WBC, fever, anorexia, or nausea and vomiting) in the pelvis.
10. Suspected urethral stricture or periurethral pathology.
11. With abdominal pain and clinical exam findings suggestive of peritonitis (such as guarding, rebound) OR abnormal inflammatory laboratory markers.

12. Suspected complications of diverticulitis unresponsive to antibiotic treatment, and CT is inconclusive or contraindicated.

    I. Evaluation of known infection or inflammatory disease follow-up:

13. Suspected abscess in the pelvis and preliminary imaging has been inconclusive.
14. History of fistula limited to the pelvis that requires re-evaluation or is suspected to have recurred.
15. Recurrent fistula or perianal Crohn’s disease.

16. Abnormal fluid collection seen on prior imaging that needs follow-up

    evaluation and is limited to the pelvis.

    J. Evaluation of Inflammatory Bowel Disease (IBD) such as Crohn’s or

    Ulcerative Colitis (includes MR enterography and can also approve

    Abdomen MRI/MRE):

17. Suspected inflammatory bowel disease after complete work up including
    physical exam, labs, and recent colonoscopy.

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2. Known inflammatory bowel disease with recurrence or worsening

   signs/symptoms requiring re-evaluation or for monitoring therapy.

   K. Hernia (known or suspected):

3. 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.
4. Hernia with suspected complications, such as strangulation or incarceration, based on physical exam (guarding, rebound) with inconclusive CT results.
5. Suspected athletic pubalgia (sports hernia) in a patient with persistent groin pain that occurs with exertion, with no ventral or inguinal hernia on exam, who has not responded to conservative treatment* for four weeks, when radiographs are nondiagnostic.

6. 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).

   L. Musculoskeletal Pelvic MRI is considered medically necessary if at least

   ONE of the following criteria are met:

7. 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.
8. For suspected fracture or stress/insufficiency fracture of the pelvis when x- rays or additional imaging are inconclusive, or for one-time evaluation to determine healing of stress/insufficiency fracture.
9. Evaluation of known or suspected aseptic/avascular necrosis of hip(s) after completion of initial x-ray. (Please refer to MRI extremities medical guideline).
10. Known or suspected sacroiliitis (infectious or inflammatory) after completion of x-ray and rheumatologic workup.

11. Sacroiliac Joint Dysfunction (after initial x-ray) when there is
    persistent back and/or sacral pain unresponsive to four (4) weeks of

    conservative treatment*, received within the past six (6) months.

12. Evaluation of the lumbosacral plexus: to confirm involvement in

    symptomatic patients with known tumor; to assess extent of injuries in the

    setting of pelvic trauma; to exclude the presence of masses in patients with

    unilateral changes, or inconclusive or abnormal findings on EMG when

    there are persistent symptoms; for evaluation when lumbar spine MRI is

    suspicious or indeterminate.

13. Suspicion of pudendal neuralgia in the setting of chronic pelvic pain with

    genital numbness and erectile dysfunction when other causes have been

    ruled out.

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8. Suspicion of meralgia paresthetica when prior testing is inconclusive

   (diagnostic nerve block; electrodiagnostic testing; AND somatosensory

   evoked potentials).

9. Persistent pain that is unresponsive to four (4) weeks of conservative treatment* received within the past six (6) months.

10. Initial imaging has been performed for evaluation of congenital

    anomalies of the sacrum and pelvis and MRI will be used to plan surgical

    intervention.

    N. Pelvic MRI is medically necessary in ANY of the following conditions,

    provided that CT has either been completed and is inconclusive, or CT is

    contraindicated:

11. Persistent abdominal/pelvic pain not explained by previous imaging.

12. In ANY of the following situations: a. Fever or leukocytosis following surgery, and no other source of infection identified. b. Fever accompanied by signs or symptoms suggesting pelvic source
    c. Fever of unknown origin (temperature of >= 101° degrees for a minimum of 3 weeks) after standard diagnostic tests are negative unexplained weight loss of > 10% body weight over the past six

    months.

13. Unexplained weight loss more than 10% of body mass over 6 months.

14. Suspected or known retroperitoneal pathology

    O. For the following conditions/evaluations, MRI of the pelvis is medically

    necessary without a preceding CT:

15. Evaluation of undescended testes in adults and in children,
    including determination of location of testes, if ordered by a specialist.
16. 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 and further characterization is required.
17. Evaluation of abnormal uterine bleeding when ultrasound findings are indeterminate: • Age <= 50-Vascular stalk or focal doppler signal on US. • Age > 50-Thickened endometrium, vascular stalk or focal doppler signal on US.
18. Evaluation of uterus prior to and after embolization of leiomyomata.
19. Evaluation of endometriosis when ultrasound has been completed and is inconclusive or indeterminate.

20. Further evaluation of suspected adenomyosis when ultrasound is

    inconclusive.

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7. For uterine masses/leiomyoma when ultrasound or clinical features suggest leiomyosarcoma.
8. Further assessment of a scrotal or penile mass when ultrasound is inconclusive.
9. Investigation of a malfunctioning penile prosthesis (provided the prosthesis is a covered benefit of the health plan).
10. Suspected urethral or periurethral mass and other imaging is inconclusive. (MRI may be indicated without prior ultrasound in limited situations as suggested, such as when there is compelling evidence suggestive of urethral diverticulum [i.e., ostia on cystoscopy or tender cystic lesion on anterior vaginal wall overlying the urethra] or for surgical planning).
11. Suspected pelvic congestion syndrome in women with chronic pelvic pain
    when other imaging is non-diagnostic.
12. Suspected patent urachus or other urachal abnormalities when ultrasound
    is non-diagnostic.
13. Diffuse, unexplained lower extremity edema with negative or
    inconclusive ultrasound.
14. Surveillance MRI (include abdomen) every 2-3 years for patients with Hereditary Paraganglioma syndrome Type 1-5.
15. Hematospermia with ALL of the following: o Age 40 years or older o Persistent hematospermia, or hematospermia accompanied by associated symptoms or signs of disease (e.g., hematuria, infertility, painful ejaculation, lower urinary tract symptoms) o Transrectal ultrasound negative or inconclusive.

16. Pelvic floor disorders, with EITHER clinical suspicion of pelvic organ prolapse OR pelvic floor disorder with urinary or bowel incontinence.

    P. Other indications:

17. Further evaluation of indeterminate findings on prior imaging (unless follow up is otherwise specified within this medical guideline): o For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification. o 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, OR with suspicious changes in symptoms or in clinical/laboratory findings).

    Q. Pre-operative evaluation for pelvic surgery or procedure.

    R. Post-operative/procedural evaluation:

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o Follow-up of known or suspected post-operative complication involving the hips or the pelvis within six months. o A follow-up study to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Must include documentation that clearly states why additional imaging is needed.

S. For any of the following Obstetric indications, provided second or third trimester ultrasound has been completed and is inconclusive, or further imaging is required to direct surgical/therapeutic options: a) Fetal anomalies b) Placental complications, including accreta and percreta
c) Pelvimetry d) Complications related to monochorionic twins e) Prior to fetal surgical intervention

T. Requests for repeat MR imaging, after completing MR of the same anatomic site in the past 6 months, will be reviewed on a case-by-case basis. The most recent imaging reports must be submitted, and for the repeat exam to be approved as medically necessary, ONE of the following MUST be met:

a) documentation that the prior testing was inconclusive, or with short-term follow-up imaging recommended. b) clinical documentation of progressive worsening of symptoms or new physical exam findings prompting the repeat imaging, and that patient management will be altered by the imaging results.
c) interval surgery (with suspected complication) or significant new trauma to that anatomic region.

*Conservative Therapy should include a combination of active and inactive

components. For inactive components: 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.

For active modalities including physical therapy, a physician-supervised home

exercise program, and/or chiropractic care.

Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.” A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

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B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

Documentation Required:

Prior authorization is required for all Pelvis MRI procedures. To obtain prior authorization, the requesting provider must submit the following information:

• A standard written order (SWO), prescribed by a qualified healthcare provider concerning the patient’s diagnosis. • Medical record information (including continued need/use if applicable) and medical necessity. • Correct coding for the service that meets all coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered. State mandates, laws or benchmark supersede this medical guideline.

Imaging is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

**All imaging related to cancer care, WPS uses NCCN as a primary reference.

Guideline Review History:

Implemented 01/01/24, 12/01/24, 09/01/25, 05/01/26 Medical Guideline Committee Approval 11/30/23, 11/21/24, 03/27/25, Q1 2026 Reviewed

11/30/23, 11/21/24, 03/27/25, Q1 2026 Developed 11/30/23

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Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Codes
Code Description

72195 Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s)
72196 Magnetic resonance (e.g., proton) imaging, pelvis; with contrast material(s)
72197 Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences
74712 MRI Fetal, including placental and maternal pelvic imaging when performed, single or first gestation
74713 MRI Fetal, including placental and maternal pelvic imaging when performed, each additional gestation (list separately in addition to code for primary procedure)
77084 Magnetic resonance bone marrow survey
0648T Quantitative magnetic resonance for analysis of tissue composition (e.g., fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (e.g., organ, gland, tissue, target structure) during the same session
0649T Quantitative magnetic resonance for analysis of tissue composition (e.g., fat, iron, water content), including multiparametric data acquisition, transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (e.g., organ, gland, tissue, structure) (List separately in addition to code for primary procedure)

ASSOCIATED CODES A9573 Injection, Gadopiclenol, 1 mg
A9575 Injection, Gadoterate meglumine, 0.1 ml
A9576 Injection, Gadoteridol, (Prohance multipack), per ml
A9577 Injection, Gadobenate Dimeglumine (Multihance), per ml
A9578 Injection, Gadobenate Dimeglumine (Multihance Multipack), per ml
A9579 Injection, Gadolium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml
A9585 Injection, Gadobutrol, 0.1 ml
Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml

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