Clinical UM Guideline
|Subject:||Diagnostic Infertility Surgery|
|Guideline #:||CG-SURG-34||Current Effective Date:||10/06/2015|
|Status:||Reviewed||Last Review Date:||08/06/2015|
This document addresses the use of hysteroscopy and laparoscopy for diagnostic work-up of infertility. Hysteroscopy is a surgical procedure used to diagnose or treat problems of the uterus. A hysteroscope is a thin, lighted telescope-like device that is inserted in the vagina and then into the uterus. The hysteroscope transmits the image of the uterus onto a screen and can assist with diagnosis of uterine problems.
Laparoscopy is a way of doing surgery without making a large cut. A thin tube known as the laparoscope is inserted into the abdomen through a small incision. The laparoscope allows visualization of the pelvic organs.
Hysteroscopy is considered medically necessary in the evaluation of infertility for any of the following indications:
Not Medically Necessary:
Hysteroscopy is considered not medically necessary when the criteria above are not met including, but not limited to all of the following:
Laparoscopy is considered medically necessary in the evaluation of infertility for any of the following indications:
Not Medically Necessary:
Laparoscopy is considered not medically necessary when the criteria above are not met including, but not limited to all of the following:
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|49320||Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)|
|58555||Hysteroscopy, diagnostic (separate procedure)|
|ICD-10 Procedure||[For dates of service on or after 10/01/2015]|
|0UJ84ZZ||Inspection of fallopian tube, percutaneous endoscopic approach|
|0UJ88ZZ||Inspection of fallopian tube, via natural or artificial opening endoscopic|
|0UJD4ZZ||Inspection of uterus and cervix, percutaneous endoscopic approach|
|0UJD8ZZ||Inspection of uterus and cervix, via natural or artificial opening endoscopic|
|0WJJ4ZZ||Inspection of pelvic cavity, percutaneous endoscopic approach|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|N88.2||Stricture and stenosis of cervix uteri|
|N96||Recurrent pregnancy loss|
|N98.0-N98.9||Complications associated with artificial fertilization|
|R93.5||Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum|
|R93.8||Abnormal findings on diagnostic imaging of other specified body structures|
|ICD-9 Procedure||[For dates of service prior to 10/01/2015]|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|622.4||Stricture and stenosis of cervix|
|629.81||Recurrent pregnancy loss without current pregnancy|
|793.5||Nonspecific (abnormal) findings on radiological and other examination of genitourinary organs|
|996.5||Mechanical complication due to other implant and internal device, not elsewhere classified|
The American Society of Reproductive Medicine (ASRM) (2015) defines infertility as the inability to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse. Work-up for the diagnosis of infertility should include a comprehensive medical, reproductive, and family history and a physical exam. Laboratory testing and diagnostic evaluation may also be appropriate with emphasis on a systematic approach beginning with the least invasive methods for diagnosis of infertility.
Tests to rule out uterine anatomic abnormalities include ultrasound, sonohysterogram, and hysterosalpingogram. Ultrasound can be done to diagnose uterine pathology such as myomas. Sonohysterogram which involves injecting saline into the uterine cavity and then using transvaginal ultrasound to view the uterine cavity can detect pathology such as endometrial polyps, submucous myomas, and synechiae. Occlusion of the fallopian tubes can cause infertility. One exam to evaluate tubal patency is a hysterosalpingogram. The hysterosalpingogram involves the use of x-rays and injection of a contrast agent into the cervical canal, uterine cavity, fallopian tubes, and peritoneal cavity to look for blockages. Hysterosalpingogram can show developmental anomalies of the uterus or acquired anomalies such as endometrial polyps or submucous myomas. A definitive method for the diagnosis and treatment of intrauterine pathology is the hysteroscopy. This exam is invasive and should be reserved for use after less invasive methods have been unsuccessful.
In a retrospective chart review, Acholonu (2011) reported on the comparison of hysterosalpingogram to sonohysterogram for detection of polyps, fibroids, adhesions and septae in infertile women. The reports were then compared to hysteroscopy. All 149 women underwent hysterosalpingogram and hysteroscopy. A total of 110 women had abnormalities found on hysteroscopy; whereas hysterosalpingogram detected abnormalities in 64 women. Ninety-three women had sonohysterogram and hysteroscopy. Of those 93 women, 77 showed abnormalities on hysteroscopy, while sonohysterogram showed abnormalities on 63 women. Those women who showed normal hysterosalpingogram or sonohysterogram did not generally go on to have hysteroscopy. Hysterosalpingogram is an important screening tool for infertile women in evaluating the architecture and patency of the fallopian tubes while sonohysterogram can be more reliable for the evaluation of intrauterine abnormalities.
According to the ASRM (2015), a laparoscopy is indicated if there is suspicion for advanced stage endometriosis, tubal occlusive disease or peritoneal factors. A 2012 retrospective review by Tsuji and colleagues reported on 127 women with suspected tubal pathology who underwent hysterosalpingogram and subsequent laparoscopy. All of the women had suspected tubal pathology found on hysterosalpingogram and 90 women were then found to have tubal pathology on laparoscopy.
A retrospective review by Robabeh and colleagues (2012) reported the findings of 181 women who had both hysterosalpingogram and laparoscopy. A total of 99 women had findings from hysterosalpingogram and laparoscopy reported as normal and 37 women had findings reported as abnormal (136 women with similar findings by the 2 methods). Forty-five women had dissimilar findings. Three women had normal hysterosalpingogram and abnormal laparoscopy, 42 women had abnormal hysterosalpingogram findings but normal findings on laparoscopy. An abnormal finding was defined as any evidence of occlusion of the fallopian tube(s) irregardless of the site of the problem. In this particular study, 75.1% of women were accurately diagnosed by hysterosalpingogram, whereas 24.9% of women had discrepant diagnoses. The authors concluded that hysterosalpingogram can be peformed first, therefore limiting the use of laparoscopy to suspected etiologies other than intratubal such as endometriosis and peritubal adhesions.
The Society of American Gastrointestinal and Endoscopic Surgeons address the use of diagnostic laparoscopy in the 2007 guidelines and based on expert opinion, state that it is indicated for infertility, particularly after a normal hysterosalpingography.
Endometriosis is a chronic gynecologic condition in which symptoms include chronic pain and infertility. It is thought to occur by the attachment and implantation of endometrial glands and stroma on the peritoneum from retrograde menstruation. Endometriosis is associated with infertility and in advanced disease anatomic abnormalities can result in abnormal tubal function. Initial treatment includes a variety of medications. If initial treatment fails, a diagnostic laparoscopy may be offered to confirm the presence of endometriosis (American College of Obstetrics and Gynecologists [ACOG], 2010, reaffirmed 2014).
Adnexal mass: A tumor or mass that occurs on any of the organs next to the uterus.
Dysmenorrhea: Painful menstrual cramps.
Hydrosalpinx: A blocked, dilated, and fluid-filled fallopian tube.
Myoma: A benign tumor of the smooth cells of the myometrium.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
|Reviewed||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and References.|
|Reviewed||08/14/2014||MPTAC review. Updated References.|
|New||08/08/2013||MPTAC review. Initial document development.|