Who reviews prior authorization requests for Ultrasound imaging of the pelvic area through the rectum (CPT 76872)?

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 Ultrasound imaging of the pelvic area through the rectum (CPT 76872)?

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 76872: Ultrasound imaging of the pelvic area through the rectum - Prior Authorization and Price

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CPT 76872

Ultrasound imaging of the pelvic area through the rectum.

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	13 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	13 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	13 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 Ultrasound imaging of the pelvic area through the rectum. Each has its own criteria for when the study is considered appropriate.

Periurethral Cysts, Urethral Diverticula, and Vaginal Masses Aetna · Cigna · UnitedHealthcare
Urinary Incontinence/Pelvic Prolapse/Fecal Incontinence Aetna · Cigna · UnitedHealthcare
Congenital (Mullerian) Uterine and Vaginal Anomalies Aetna · Cigna · UnitedHealthcare
Male Pelvic Disorders Aetna · Cigna · UnitedHealthcare
Pelvic Pain/Dyspareunia, Female Aetna · Cigna · UnitedHealthcare
Colorectal and Small Bowel Cancer Aetna · Cigna · UnitedHealthcare
Prostate Cancer Aetna · Cigna · UnitedHealthcare

Typical price

Commercial insurance, median

$300

Middle half of rates: $174 to $532

Medicare, hospital outpatient

$107

Facility payment

Medicare, physician fee schedule

$121

National, non-facility

Commercial figures come from negotiated rates published by 853 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 Ultrasound imaging of the pelvic area through the rectum change.

CPT 76872: Ultrasound imaging of the pelvic area through the rectum - 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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