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).