dysfunctional uterine bleeding & uterine fibroids - Health Plan of ...
dysfunctional uterine bleeding & uterine fibroids - Health Plan of ...
dysfunctional uterine bleeding & uterine fibroids - Health Plan of ...
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WOU001<br />
APPLICABLE CODES<br />
The codes listed in this policy are for reference purposes only. Listing <strong>of</strong> a service or device code in<br />
this policy does not imply that the service described by this code is a covered or non-covered health<br />
service. Coverage is determined by the benefit document. This list <strong>of</strong> codes may not be all inclusive.<br />
CPT ® Code Description<br />
Focused ultrasound ablation <strong>of</strong> <strong>uterine</strong> leiomyomata, including MR guidance; total<br />
0071T<br />
leiomyomata volume less than 200 cc <strong>of</strong> tissue<br />
Focused ultrasound ablation <strong>of</strong> <strong>uterine</strong> leiomyomata, including MR guidance; total<br />
0072T<br />
leiomyomata volume greater or equal to 200 cc <strong>of</strong> tissue<br />
Uterine fibroid embolization (UFE, embolization <strong>of</strong> the <strong>uterine</strong> arteries to treat<br />
<strong>uterine</strong> <strong>fibroids</strong>, leiomyomata), percutaneous approach inclusive <strong>of</strong> vascular access,<br />
37210 vessel selection, embolization, and all radiological supervision and interpretation,<br />
intraprocedural roadmapping, and imaging guidance necessary to complete the<br />
procedure<br />
58353 Endometrial ablation, thermal, without hysteroscopic guidance<br />
Endometrial cryoablation with ultrasonic guidance, including endometrial<br />
58356<br />
curettage, when performed<br />
Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection,<br />
58563<br />
electrosurgical ablation, thermoablation)<br />
CPT ® is a registered trademark <strong>of</strong> the American Medical Association.<br />
HCPCS Code<br />
J7302<br />
J7306<br />
S4981<br />
Description<br />
Levonorgestrel-releasing intra<strong>uterine</strong> contraceptive system, 52 mg<br />
Levonorgestrel (contraceptive) implant system, including implants and supplies<br />
Insertion <strong>of</strong> levonorgestrel-releasing intra<strong>uterine</strong> system<br />
ICD-9 Codes Description<br />
617.0 Endometriosis <strong>of</strong> uterus<br />
617.9 Endometriosis, site unspecified<br />
626.0 Absence <strong>of</strong> menstruation<br />
626.1 Scanty or infrequent menstruation<br />
626.2 Excessive or frequent menstruation<br />
626.3 Puberty <strong>bleeding</strong><br />
626.4 Irregular menstrual cycle<br />
626.5 Ovulation <strong>bleeding</strong><br />
626.6 Metrorrhagia<br />
626.7 Postcoital <strong>bleeding</strong><br />
626.8<br />
Other disorder <strong>of</strong> menstruation and other abnormal <strong>bleeding</strong> from<br />
female genital tract<br />
626.9<br />
Unspecified disorder <strong>of</strong> menstruation and other abnormal <strong>bleeding</strong><br />
from female genital tract<br />
627.0 Premenopausal menorrhagia<br />
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