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

Effective Date

09/01/2023

Last Reviewed

02/16/2023

Original Document

  Reference



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.