Cigna Pelvis Imaging Amendment to Cigna-eviCore General Pelvis Imaging Guideline - (DV001) Form

The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment and have discretion in making individual coverage determinations. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

This Cigna Coverage Policy replaces Section 3.1: Secondary Amenorrhea in the Cigna-eviCore General (Adult) Pelvis Imaging guideline and applies to Cigna-administered benefit plans. All other portions of the Cigna-eviCore General Pelvis Imaging guideline remain in effect. This Amendment applies to the Cigna-eviCore General Pelvis Imaging guideline.

Amendment Pelvis 3.1: Secondary Amenorrhea

Pelvic ultrasound (CPT® 76856 or CPT® 76857) and/or transvaginal ultrasound (CPT® 76830) is considered medically necessary for secondary amenorrhea when BOTH of the following criteria are met:

• negative pregnancy test • elevated serum free testosterone, to rule out an androgen producing ovarian tumor

Medical Coverage Policy DV001

• For suspected adrenal tumor, See Adrenal Cortical Lesions (AB-16) in the General Abdomen Imaging Guidelines located at https://www.evicore.com/cigna.
• For suspected pituitary tumor, See Pituitary (HD-19) in the general Head Imaging Guidelines located at https://www.evicore.com/cigna.
• For suspected Asherman’s Syndrome:
  • Hysterosalpingogram (CPT® 74740), sonohysterosalpingography (CPT® 76831), and/or hysteroscopy if ultrasound is indeterminate for Asherman’s syndrome.
• MRI Pelvis without contrast (CPT® 72195) or without and with contrast (CPT® 72197) if hysterosalpingogram (CPT® 74740), sonohysterosalpingography (CPT® 76831), or hysteroscopy is indeterminate for Asherman’s Syndrome