Which payers have published criteria for CT pelvis without contrast (CPT 72192)?

The imaging guidelines used by Aetna, Anthem BCBS, Cigna, Medicare, UnitedHealthcare include criteria that apply to this study. Whether a specific patient's plan requires prior authorization depends on the plan, so confirm on the payer's portal or by phone before scheduling.

Who reviews prior authorization requests for CT pelvis without contrast (CPT 72192)?

Most commercial payers hand imaging reviews to a radiology benefit manager. For the payers tracked here, requests are reviewed using guidelines from eviCore, Carelon, CMS, UnitedHealthcare / eviCore. The request is submitted through that organization's portal rather than the health plan's general line.

What should be in the clinical notes before requesting CT pelvis without contrast (CPT 72192)?

Reviewers look for a recent office visit that documents the symptoms and how long they have lasted, exam findings, results of any earlier imaging, treatments already tried and how the patient responded, and the specific question the study is expected to answer. The diagnosis code on the request should match what the notes describe.

How much does CT pelvis without contrast (CPT 72192) cost?

Across 1,089 hospitals that publish their negotiated rates, the median commercial insurance rate is $718, with the middle half of rates between $335 and $1,468. A patient's own cost depends on their plan, deductible and where the study is done.

What can be done if CT pelvis without contrast (CPT 72192) is denied?

Read the denial letter for the stated reason, then request a peer-to-peer conversation between the ordering clinician and the reviewing physician, which often resolves missing-information denials. If that fails, file a written appeal that answers the stated reason directly and attach the supporting notes. The denial letter lists the deadline and where to send the appeal.

CPT 72192: CT pelvis without contrast - Prior Authorization and Price

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CPT 72192

CT imaging of the pelvis is performed without using contrast dye.

CT Abdomen & Pelvis

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Pelvis Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Musculoskeletal Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Spine Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Abdomen Imaging Guidelines 1.0.2026, effective Feb 3, 2026	14 that name this code
Anthem BCBS	Carelon	Oncologic imaging effective Apr 4, 2026 Imaging of the abdomen and pelvis effective Apr 4, 2026 Advanced imaging for vascular indications effective Sep 19, 2026	89 that name this code
Cigna	eviCore	Pelvis Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Musculoskeletal Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Spine Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Abdomen Imaging Guidelines 1.0.2026, effective Feb 3, 2026	14 that name this code
Medicare	CMS	NCD 220.1: Computed Tomography effective Mar 12, 2008	1 that name this code
Original Medicare does not run a prior authorization program for outpatient imaging; claims are judged against the coverage policies above. Medicare Advantage plans set their own prior authorization rules.
UnitedHealthcare	UnitedHealthcare / eviCore	Commercial and Exchange Cardiovascular and Radiology Imaging Guidelines 09.2026, effective Sep 1, 2026	14 that name this code

Guidelines collected from the payers' published documents on September 29, 2026. Payers revise these documents during the year. Open the guideline link to confirm the current version before you submit.

Conditions the guidelines address for this study

These are the clinical situations where payer guidelines discuss CT pelvis without contrast. Each has its own criteria for when the study is considered appropriate.

Abdominal and/or pelvic pain, undifferentiated Anthem BCBS
Acute Leukemia Anthem BCBS
Anal Cancer Anthem BCBS
Aneurysm of the abdominal aorta or iliac arteries Anthem BCBS
Aortic dissection and other aortopathies Anthem BCBS
Appendicitis Anthem BCBS
Avascular necrosis, bilateral hip Anthem BCBS
Bariatric procedure-related imaging Anthem BCBS
Bladder and Urothelial Cancers Anthem BCBS
Bladder/Urothelial Cancers: Muscle Invasive Anthem BCBS
Bladder/Urothelial Cancers: Non-muscle Invasive Anthem BCBS
Bone Sarcoma Anthem BCBS
Bowel obstruction Anthem BCBS
Brain and Spinal Cord Malignancy Anthem BCBS
Breast Cancer Anthem BCBS
Cancer screening, not otherwise specified Anthem BCBS
Cancers of the Pleura, Thymus, Heart, and Mediastinum Anthem BCBS
Cancers of Unknown Primary / Cancers Not Otherwise Specified Anthem BCBS
Cervical Cancer Anthem BCBS
Chronic lymphocytic leukemia or small lymphocytic lymphoma Anthem BCBS
Colorectal Cancer Anthem BCBS
Colorectal cancer screening Anthem BCBS
Congenital and developmental conditions, not otherwise specified Anthem BCBS
Congenital or developmental vascular anomalies, not otherwise specified Anthem BCBS
Constipation (Pediatric only) Anthem BCBS
Developmental hip dysplasia (Pediatric only) Anthem BCBS
Diverticulitis Anthem BCBS
Enteritis or colitis, not otherwise specified Anthem BCBS
Esophageal and Gastroesophageal Junction Cancers Anthem BCBS
Fever of unknown origin Anthem BCBS
Gastric Cancer Anthem BCBS
Gastrointestinal bleeding Anthem BCBS
Gastrointestinal stromal tumor (GIST) Anthem BCBS
Head and Neck Cancer Anthem BCBS
Hematoma/hemorrhage within the abdomen or pelvis Anthem BCBS
Hematuria (painless or undifferentiated) Anthem BCBS
Hemoperitoneum Anthem BCBS
Hepatocellular and Biliary Tract Cancers Anthem BCBS
Hernia Anthem BCBS
Histiocytic Neoplasms Anthem BCBS

Plus 61 more. Use the search below to find a specific condition.

Typical price

Commercial insurance, median

$718

Middle half of rates: $335 to $1,468

Medicare, hospital outpatient

$107

Facility payment

Medicare, physician fee schedule

$133

National, non-facility

Commercial figures come from negotiated rates published by 1,089 hospitals; Medicare figures from CMS fee schedules. Rates vary widely by hospital and plan. Pricing data from CenterIQ.

Get notified when the rules for this study change

Payers update imaging guidelines several times a year. We will email you when the criteria for CT pelvis without contrast change.

CPT 72192: CT pelvis without contrast - Prior Authorization and Price

Payer guidelines that apply

Conditions the guidelines address for this study

Typical price

Get notified when the rules for this study change

Frequently asked questions

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CPT 72192: CT pelvis without contrast - Prior Authorization and Price

Payer guidelines that apply

Conditions the guidelines address for this study

Typical price

Get notified when the rules for this study change

Frequently asked questions

Related studies

Imaging CPT Code Coverage Lookup

Quick Access - Common Imaging CPT Codes

CT

MRI

MRA

PET