CG-SURG-34 Diagnostic Hysteroscopy for Infertility

This policy addresses diagnostic hysteroscopy for the evaluation of infertility. It is medically necessary when there is suspected uterine abnormality on an abnormal hysterosalpingogram or sonohysterogram (e.g., endometrial polyp, submucosal myoma/fibroid, intrauterine adhesions, congenital uterine anomaly), proximal tubal occlusion on HSG, cervical stenosis, or an inadequate/non-diagnostic HSG or sonohysterogram; it is not covered for infertility when these criteria are not met, and non-infertility indications are outside the policy’s scope.

"Hysteroscopy is consideredmedically necessaryin the evaluation of infertility for any of the following indications:"

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