Anthem Blue Cross Connecticut CG-SURG-34 Diagnostic Hysteroscopy for Infertility Form
This procedure is not covered
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.
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