Diagnosis: Gynecological/Gynecological/Pelvic and Perineal Pain
Treatment: Radiology Services/Computed tomography (CT) of the abdomen and pelvis with contrast
The health plan denied the requested computed tomography (CT) of the abdomen and pelvis with contrast as not medically necessary. The health plan's determination is upheld.

This is a female patient with a stated diagnosis of pelvic congestion syndrome (by history) who presented with pelvic heaviness and a variety of urinary symptoms. A computed tomography (CT) venogram of the abdomen and pelvis performed was interpreted as normal, with normal pelvis venous vasculature.
At issue is the medical necessity for the requested CT of the abdomen and pelvis with contrast.

The health plan's determination of medical necessity is upheld, in whole.

No. The patient does not satisfy plan criteria for the CT scan of the abdomen and pelvis with contrast to be considered medically necessary. There has not been an initial pelvic ultrasound performed to investigate the unexplained pelvic pain and/or dyspareunia. There has also not been any appropriate urological workup for the patient's urinary symptoms. Plan criteria is based upon peer-reviewed literature and accepted standards of medical practice. The CT scan of the abdomen/pelvis with contrast is not medically necessary.