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).