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Pelvis Imaging Amendment to Cigna-eviCore General Pelvis …

Page 1 of 4 Medical Coverage Policy DV001 Medical Coverage Policy Effective Date ..02/01/2022 Next Review Date ..08/15/2022 Coverage Policy Amendment .. DV001 Pelvis Imaging Amendment to Cigna-eviCore General Pelvis Imaging Guideline Table of Contents Overview .. 1 Amendment .. 1 References .. 3 Related Coverage Resources General Pelvis Imaging Guideline Transvaginal Ultrasound, Non-Obstetrical INSTRUCTIONS FOR USE 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.

American Urological Association Education and Research, Inc., et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011 Jun;185(6):2162-70. 8. Kraemer S, Watson V, Peters KM. The Evaluation and Management of Interstitial Cystitis/Bladder Pain Syndrome. EMJ Urol 2019;7(1):75-82. 9.

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