Z97.5 — Presence of (intrauterine) contraceptive device
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For embryo transfer guidance: documentation that US guidance was used during embryo transfer and catheter type if relevant (policy notes trials that compared US-guided transfer with clinical touch and catheter type can affect outcomes).
- For cervical length screening: gestational age at measurement; measured cervical length and documentation of follow-up TV-US if cervical length is less than 25 mm (policy: "Women with cervical length less than 25 mm at 14 to 28 weeks should undergo a subsequent transvaginal ultrasound to confirm this finding").
- For monitoring hereditary risk of ovarian cancer: documentation of high-risk status (policy example: "Transvaginal ultrasound may be medically necessary for monitoring women with Lynch II syndrome (BRCA2 mutation) for ovarian cancer").
Key Coverage Criteria
- Evaluation of abnormal uterine bleeding;
- Evaluation of congenital uterine anomalies;
- Evaluation of infertility;
- Transvaginal sonography with color Doppler for prenatal diagnosis of vasa previa (identification of membranous fetal vessels passing across or near the internal cervical os).
- Transvaginal ultrasound as the primary imaging modality for suspected ectopic pregnancy (TVUS is the imaging test of choice to determine pregnancy location and should be performed at presentation and repeated as indicated).
- Assessment of a pelvic mass (e.g., adenomyosis, cancer, cyst, and fibroid);
2 Active Policies
AMBETTER-CP.MP.97 — Testing for Select Genitourinary Conditions
AETNA-CPB-0530 — Transvaginal Ultrasonography
Related Codes
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