1.0 CPT
PROCEDURE CODES
11975 - 11977, 37243,
55970, 55980, 56405 - 58301, 58340, 58345, 58346,
58350, 58353, 58356, 58400 - 58673,
58679, 58700 - 58740, 58750 - 58770, 58800
- 58960, 58999, 59001
3.0 POLICY
3.1 Services
and supplies required in the diagnosis and treatment of illness
or injury involving the female genital system are covered. Infertility
testing and treatment, including correction of the physical cause
of infertility, are covered under this provision.
3.2 Uterine
suspension; parametrial fixation as treatment for uterine prolapse
may be cost-shared only to retain the uterus for biologic purposes.
3.3 Sex
gender change and intersex surgery (Current Procedural
Terminology (CPT) procedure code
55970 and 55980)
is limited to surgery performed to treat ambiguous genitalia which
is documented to have been present at birth. Also see
Section 16.1.
3.4 Medically
necessary reversal of surgical sterilization for the treatment of
a disease or injury such as chronic pelvic pain (CPT procedure codes
58672, 58673, 58750 - 58770) may be cost-shared.
Note: For policy on prophylactic mastectomy, prophylactic
oophorectomy, and prophylactic hysterectomy, see
Section 5.3.
4.0 POLICY
CONSIDERATION
Benefits are payable for Uterine
Artery Embolization (UAE), as an alternative treatment (CPT procedure
code 37243) to hysterectomy or myomectomy,
for those individuals with confirmed, symptomatic uterine fibroids
who are premenopausal and who do not wish to preserve their childbearing
potential.
5.0 EXCLUSIONS
5.1 Prophylactics
(condoms).
5.2 Over-the-counter (OTC) spermicidal products.
5.3 Reversal
of a surgical sterilization procedure (CPT procedure codes 58672,
58673, 58750 - 58770)
, except as stated in paragraph 3.4.
5.4 Artificial
insemination, including any costs related to donors and semen banks
(CPT procedure codes 58321 - 58323).
5.5 In Vitro Fertilization (IVF),
Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT),
Tubal Embryo Transfer (TET), and all other non-coital reproductive
procedures, including all services and supplies related to, or provided
in conjunction with, those technologies (CPT procedure codes 58970
- 58976).
5.6 Hysterectomy (CPT procedure codes 58150 - 58285,
58550, 59525) performed solely for purposes of sterilization in
the absence of pathology.
5.7 Cervicography (CPT category
III procedure code 0003T) is unproven.
5.8 UAE for individuals with specific
contraindications, including such conditions as pelvic malignancy
and pelvic inflammatory disease, and premenopausal patients who
wish to preserve their childbearing potential.
5.9 Ultrasound
ablation (destruction of uterine fibroids) with Magnetic Resonance
Imaging (MRI) guidance (CPT procedure code 0071T) in the treatment
of uterine leiomyomata is unproven.
5.10 Percutaneous transcatheter
embolization of ovarian and/or internal iliac veins for the treatment
of Pelvic Congestion Syndrome (PCS) is unproven.
5.11 All services and supplies directly
and indirectly related to surgical treatment (i.e., sex gender change)
except when performed to correct ambiguous genitalia, which is documented
to have been present at birth (CPT procedure codes 55970 and 55980).