Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Transvaginal Ultrasounds are covered when there are signs and symptoms present that indicate an abnormality of the female pelvis.

2)    Transvaginal Ultrasounds will not be covered in the following circumstances:

a)    Transvaginal Ultrasound is not covered for screening for ovarian cancer or when there are no problems or symptoms present.

b)    Non-OB Pelvic Ultrasound examinations are not covered in the initial evaluation,    diagnosis, treatment or follow-up of infertility.

3)    Transvaginal Ultrasounds may be reviewed and denied after services are rendered and paid. In such cases, the member may have financial responsibility.

1)    QualChoice acknowledges the importance of ultrasound visualization as a tool in the evaluation of abnormalities or complaints referable the female pelvis. The evaluation of female pelvic signs and symptoms should progress through an orderly process of obtaining an appropriate history and performance of a pelvic examination. If an abnormality is detected on physical examination which needs further elucidation, or if the appropriate course of treatment is unclear, a high-quality, well documented complete ultrasound examination of the pelvis is warranted to assure that all anatomic structures, normal and abnormal, are visualized. This examination should be carefully documented to permit future comparison.

a)    When 76830 is billed in conjunction with 76856, to indicate that both trans-abdominal and transvaginal examinations were conducted at the same visit in order to establish complete visualization of the pelvic anatomy, the payment for the 76830 will be reduced by 50% to reflect its status as a secondary procedure.

2)    QualChoice views the use of a limited transvaginal ultrasound as an appropriate study to follow pelvic abnormalities seen on previous imaging studies. QualChoice would expect documentation of the previously noted problem and documentation of the measurement of the current examination compared with the previous examination.

3)    Transvaginal screening ultrasound in asymptomatic women to check for signs of ovarian cancer has been studied and has not been supported in the literature. QualChoice deems this use of ultrasound to be experimental and therefore not covered.

4)    Independent non-Obstetrical Transvaginal Ultrasound is covered as an examination for ovarian cancer when 2 or more of the following symptoms have been present continuously for 2 weeks or more:

a)    Abdominal bloating; OR

b)    Pelvic or abdominal pain; OR

c)     Difficulty eating or feeling of fullness on eating; OR

d)    Urinary frequency or urgency; OR

e)    A pelvic exam has revealed a suspicion of ovarian mass.

5)    Independent Transvaginal Ultrasound is considered medically necessary in the evaluation of a woman who has a positive pregnancy test and symptoms of pain or bleeding suggesting that an ectopic pregnancy may be present. 76830 should not be used as the billing code for this procedure. Use 76817 instead.

6)    Because the indications for isolated, transvaginal Ultrasonography are limited, and there are indications for which the examination is excluded from coverage, QualChoice will audit high volume providers retrospectively for compliance with this policy. QualChoice will expect to find all of the following present in the materials submitted to substantiate charges during an audit:

a)    The history and physical examination will be documented.

b)    There will be a dictated report for the procedure. That report will include:

i)       The indication for the procedure.

ii)     An indication whether the examination was considered to be a complete assessment of the pelvis or only an incomplete examination. If the latter, reference should be made to the date ad findings of a previous complete examination

iii)    The specific findings of the examination, including the evaluation and measurement of all pelvic structures, including the uterus, both fallopian tubes, both ovaries, and any pathologic structures encountered (or an indication of their absence based on some other evidence).

Codes Used In This BI:

76830           Transvaginal us non-ob

76856           Us exam pelvic complete

76857           Us exam pelvic limited

1)    Transvaginal ultrasound is not covered for screening for ovarian cancer or in the absence of symptoms.

2)    Pelvic ultrasound examinations are not covered in the initial evaluation, diagnosis, treatment or follow-up of infertility, including in the term “infertility” any inquiry or investigation done to ascertain or assess fertility or infertility or to create a prognostic statement about the likelihood of spontaneous conception regardless of whether a diagnosis of infertility is being considered or whether treatment of infertility would be contemplated if that diagnosis were made. (Infertility treatment is covered by some self-funded plans – please refer to the Summary Plan Description for further information.)

3)    The use of code 76857 will also be audited.

1)    American Cancer Society; Ovarian Cancer has early symptoms, Jun14, 2007 at: http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Ovarian_Cancer_Symptoms_The_Silence_Is_Broken.asp

2)    U.S. Preventative Services Task Force; Ovarian Cancer screening, May, 2004 at: http://www.ahrq.gov/clinic/uspstf/uspsovar.htm

3)    Barbara A. Goff, MD et al; Frequency of symptoms of ovarian cancer in women presenting to primary care clinics, JAMA, 2004;291:2705-2712 at: http://jama.ama-assn.org/cgi/content/abstract/291/22/2705

4)    Ovarian cancer symptoms consensus statement; Gynecologic Cancer Foundation at: http://jama.ama-assn.org/cgi/content/abstract/291/22/2705

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.