58578
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Providers must use the most appropriate codes as of the effective date of the submission. Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.
- Reimbursement is not allowed for services when billed for conditions or diagnoses that are not covered under this Coverage Policy.
- For antenatal (during pregnancy) transabdominal/laparoscopic cervical cerclage: documentation should support pregnancy status and one or more of the qualifying criteria: prior failed history-indicated transvaginal cervical cerclage; prior cervical trauma (e.g., cone biopsy, cervical laceration during delivery); shortened cervical length.
- For cerclage performed on a non-pregnant individual: documentation should support one or more qualifying criteria: prior failed history-indicated transvaginal cervical cerclage; prior cervical trauma (e.g., cone biopsy, cervical laceration during delivery); shortened cervical length.
Key Coverage Criteria
- The following treatments are considered medically necessary for recurrent pregnancy loss: antenatal (during pregnancy) transabdominal/laparoscopic cervical cerclage for an individual with ANY of the following conditions: prior failed history-indicated transvaginal cervical cerclage; prior cervical trauma (e.g., cone biopsy, cervical laceration during delivery); shortened cervical length.
- The following treatments are considered medically necessary for recurrent pregnancy loss: cerclage performed on a non-pregnant individual with ANY of the following conditions: prior failed history-indicated transvaginal cervical cerclage; prior cervical trauma (e.g., cone biopsy, cervical laceration during delivery); shortened cervical length.
- Cervical cerclage procedures (when criteria above are met) represented by CPT codes listed in the policy: 57700 (Cerclage of uterine cervix, nonobstetrical); 59325 (Cerclage of cervix, during pregnancy; abdominal); and when appropriate unlisted procedure codes for laparoscopic or nonobstetrical approaches (58578, 58999) as noted in the Coding Information.
1 Active Policy
CIGNA-0284 — Recurrent Pregnancy Loss: Diagnosis and Treatment - (0284)
Related Codes
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