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Anthem Blue Cross ConnecticutCommercial Clinical Policy

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


Hysteroscopy for evaluation of infertility with suspected uterine abnormality

Indications

(917658) Is there a suspected uterine abnormality as evidenced by an abnormal hysterosalpingogram or hysterosonogram (for example, endometrial polyp, submucosal myoma, intrauterine synechia, or uterine anomaly)? 

Hysteroscopy for evaluation of infertility with proximal tubal occlusion

Indications

(917659) Is there proximal tubal occlusion as determined by a hysterosalpingogram? 

Hysteroscopy for evaluation of infertility with cervical stenosis

Indications

(917660) Does the patient have cervical stenosis? 

Hysteroscopy for evaluation of infertility with inadequate or non-diagnostic HSG/Sonohysterogram

Indications

(917661) Was the hysterosalpingogram or sonohysterogram inadequate or non-diagnostic? 

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.