58674
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
13.73
Facility
$720.46
Non-Facility
$720.46
Documentation Required
- No explicit documentation requirements, required medical records, test results, or clinical documentation are stated in this document chunk.
- Please refer to CMS Medicare Coverage Database for the most current applicable CMS National Coverage Determination (NCD)/Local Coverage Determination (LCD)/Local Coverage Article (LCA).
- Refer to CMS website for the most current applicable CMS Online Manual System (IOMs) and Transmittals.
- Documentation of symptoms attributable to fibroids (eg, excessive bleeding, pelvic pain, pressure) (inferred from text)
Key Coverage Criteria
- Myomectomy performed via hysteroscopy
- Myomectomy performed via laparoscopy
- Myomectomy performed via laparotomy
- Uterine fibroids (leiomyomas or myomas) — noncancerous growths of the uterus
- Symptomatic uterine fibroids (eg, excessive bleeding, pain, pressure) where medical or surgical treatment may be warranted
- Surgical options for symptomatic fibroids that have not responded to medical treatment
1 Active Policy
HUMANA-UTERINE-FIBROID-SURGICAL-TREATMENTS-MA — Uterine Fibroid Surgical Treatments - Medicare Advantage
Related Codes
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