Who reviews prior authorization requests for Limited ultrasound examination of the pelvic region (CPT 76857)?

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 Limited ultrasound examination of the pelvic region (CPT 76857)?

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.

CPT 76857: Limited ultrasound examination of the pelvic region - Prior Authorization and Price

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CPT 76857

Limited ultrasound examination of the pelvic region.

Ultrasound

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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 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Abdomen Imaging Guidelines 1.0.2026, effective Feb 3, 2026 Pediatric Abdomen Imaging Guidelines 2.0.2026, effective Sep 1, 2026	42 that name this code
Anthem BCBS	Carelon	Current guideline	None found
Cigna	eviCore	Pelvis Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Abdomen Imaging Guidelines 1.0.2026, effective Feb 3, 2026 Pediatric Abdomen Imaging Guidelines 2.0.2026, effective Sep 1, 2026	43 that name this code
Medicare	CMS	—	None found
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	42 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 Limited ultrasound examination of the pelvic region. Each has its own criteria for when the study is considered appropriate.

Adnexal Mass/Ovarian Cysts Aetna · Cigna · UnitedHealthcare
Amenorrhea Aetna · Cigna · UnitedHealthcare
Leiomyoma/Uterine Fibroids and other Uterine Masses Aetna · Cigna · UnitedHealthcare
Periurethral Cysts, Urethral Diverticula, and Vaginal Masses Aetna · Cigna · UnitedHealthcare
Abnormal Uterine Bleeding Aetna · Cigna · UnitedHealthcare
Congenital (Mullerian) Uterine and Vaginal Anomalies Aetna · Cigna · UnitedHealthcare
Intrauterine Device (IUD) and Tubal Occlusion Aetna · Cigna · UnitedHealthcare
Adenomyosis Aetna · Cigna · UnitedHealthcare
Endometriosis Aetna · Cigna · UnitedHealthcare
Male Pelvic Disorders Aetna · Cigna · UnitedHealthcare
Patent Urachus Aetna · Cigna · UnitedHealthcare
Pelvic Inflammatory Disease (PID) Aetna · Cigna · UnitedHealthcare
Pelvic Pain/Dyspareunia, Female Aetna · Cigna · UnitedHealthcare
Penis–Soft Tissue Mass Aetna · Cigna · UnitedHealthcare
Polycystic Ovary Syndrome Aetna · Cigna · UnitedHealthcare
Urinary Incontinence/Pelvic Prolapse/Fecal Incontinence Aetna · Cigna · UnitedHealthcare
Testicular, Ovarian and Extragonadal Germ Cell Tumors Aetna · Cigna · UnitedHealthcare
Hematuria Aetna · Cigna · UnitedHealthcare
Ovarian Cancer Aetna · Cigna · UnitedHealthcare
Hematopoietic Stem Cell Transplantation (HSCT) Aetna · Cigna · UnitedHealthcare
Hernias Aetna · Cigna · UnitedHealthcare
Melanomas and Other Skin Cancers Aetna · Cigna · UnitedHealthcare
Screening Imaging in Cancer Predisposition Syndromes Aetna · Cigna · UnitedHealthcare
Spleen Aetna · Cigna · UnitedHealthcare

Typical price

Commercial insurance, median

$252

Middle half of rates: $144 to $459

Medicare, hospital outpatient

$107

Facility payment

Medicare, physician fee schedule

$51

National, non-facility

Commercial figures come from negotiated rates published by 1,042 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 Limited ultrasound examination of the pelvic region change.

CPT 76857: Limited ultrasound examination of the pelvic region - 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

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