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TRICARE Policy Manual 6010.60-M, April 1, 2015
Surgery
Chapter 4
Section 17.1
Female Genital System
Issue Date:  August 26, 1985
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-1, March 10, 2017
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
2.0  DESCRIPTION
The female genital system includes the female organs of reproduction.
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).
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