Anthem Blue Cross Connecticut CG-SURG-34 Diagnostic Hysteroscopy for Infertility Form

This document addresses the use of hysteroscopy for the diagnostic work-up of infertility.

Clinical Indications

Hysteroscopy

Medically Necessary:

Hysteroscopy is considered medically necessary in the evaluation of infertility for any of the following indications:

• Suspected uterine abnormality as evidenced by abnormal hysterosalpingogram or hysterosonogram (for example, but not limited to endometrial polyp, submucosal myoma, intrauterine synechia (scarring) or uterine anomaly (unicornuate, bicornuate, septate uteri); or
• Proximal tubal occlusion on hysterosalpingogram; or
• Cervical stenosis; or
• Inadequate or non-diagnostic hysterosalpingogram or sonohysterogram.

Not Medically Necessary:

Hysteroscopy in the evaluation of infertility is considered not medically necessary when the above criteria have not been met*.

*Note: hysteroscopy for indications other than infertility are not within scope of this document.