1.0 CPT 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) codes 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 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 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 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 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 codes 58970 - 58976).
5.6 Hysterectomy (CPT codes 58150
- 58285, 58550, 59525) performed solely for purposes of sterilization
in the absence of pathology.
5.7 Cervicography
(CPT category III 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
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 codes 55970 and 55980).