58555
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.58
Facility
$134.61
Non-Facility
$328.00
Key Coverage Criteria
- Hysteroscopy is consideredmedically necessaryin 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.
1 Active Policy
ANTHEM-CG-SURG-34 — CG-SURG-34 Diagnostic Hysteroscopy for Infertility
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.