MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Hysterectomy Surgery

Number 7.01.548

Effective Date May 12, 2015

Revision Date(s) 05/12/15; 12/22/14; 06/09/14, 02/10/14; 09/09/13; 02/22/13

Replaces N/A

Policy

Hysterectomy surgery, with or without salpingo-oophorectomy, may be considered medically necessary when the following specific criteria are met:

  • Malignant (cancer) Gynecologic Indications

Hysterectomy* surgery with or without salpingo-oophorectomy* may be considered medically necessary for ANY of the following:

  • A diagnosed malignancy (cancer) of the uterus, cervix, ovaries, fallopian tubes or endometrium OR
  • In situations where clinical features are highly suspicious for malignancy (e.g. a mass suspicious for ovarian cancer) OR
  • Prophylactic gynecologic cancer prevention for 1 or more of the following:
  • Hereditary nonpolyposis colorectal cancer (e.g. Lynch syndrome)
  • Positive BRCA mutation found on a genetic test OR
  • Malignant gestational trophoblastic disease (choriocarcinoma)
  • Non-malignant (not cancer) Gynecologic Indications

Hysterectomy surgery, with or without salpingo-oophorectomy, may be considered medically necessary when ALL of the following criteria are met:

  • Symptoms are present for at least 6 months and interfere with activities of daily living on 1 or more days per month that may include but are not limited to the following:
  • Heavy uterine bleeding
  • Iron deficiency anemia
  • Pain with intercourse
  • Pelvic pain or pressure
  • Urinary or bowel problems caused by the uterus

AND

  • Tests are done to discover a reason for the symptoms (e.g. endometrial sampling, hysteroscopy, laparoscopy, pelvic ultrasound, and others) or there is a documented reason why testing is not appropriate or was declined by the patient;

AND

  • Other treatment(s) for the symptoms were tried and failed to provide relief, cannot be used because of another medical condition or were declined by the patient (see Required Documentation). These treatments may include but are not limited to:
  • Hormonal therapy (e.g., progestins, gonadotropin releasing hormones, oral birth control pills); OR
  • Uterine-sparing procedures (e.g., endometrial ablation, uterine artery/fibroid embolization (UAE/UFE) or myomectomy); OR
  • Non-surgical uterine prolapse support (e.g. pessary, pelvic floor exercises)

AND

Hysterectomy surgery is considered not medically necessary when no clinical indication is documented and there are no confirmatory physical and test findings that meet the medical necessity criteria for the surgery.

Note: The provider’s choice of interventional hysterectomy surgery (e.g. abdominal, laparoscopic, or vaginal) depends on the specific member’s symptoms and physical/imaging findings.

Related Policies

7.01.109

Magnetic Resonance Imaging-Guided Focused Ultrasound (MRgFUS)

7.01.557

Gender Reassignment Surgery

Policy Guidelines

Definition of Terms

  • Abnormal uterine bleeding (AUB): Heavy menstrual bleeding that requires repeated changing of a tampon/menstrual pad more often than every two hours, menstrual periods that last longer than 7 days or repeat at intervals less than 21-days apart. Bleeding after menopause is abnormal.
  • Choriocarcinoma: A type of gestational trophoblastic disease is a rare form of cancer that grows rapidly from the cells of the placenta.
  • Dysmenorrhea: Painful periods that may include severe menstrual cramps. Dysmenorrhea is problematic when the pain occurs monthly for at least 6 months and is so severe that it interferes with daily activities.
  • Fibroids: Also known as myomas or leiomyoma are non-cancerous tumors/ growths within the wall of the uterus. Fibroids usually occur as multiple; in varying shapes and at various sites within the uterus. Fibroids can cause painful symptoms and abnormal bleeding from the uterus.
  • Fibroid Embolization: Is a minimally invasive uterine sparing procedure. The procedure involves the insertion of a substance through a catheter to stop the uterine artery blood flow to fibroids causing them to shrink.
  • Hysterectomy: The surgical removal of the uterus either through the abdominal wall or through the vagina.
  • Menorrhagia: Excessively prolonged or heavy menstruation. (see abnormal uterine bleeding)
  • Pelvic floor disorder (PFD): Results when the connective tissue and muscles of the pelvis weaken or are injured. The most common PFDs are pelvic organ prolapse such as uterus, bladder, bowel.
  • Salpingo-oophorectomy: The surgical removal of the fallopian tubes and ovaries through the abdominal wall or through the vagina.
  • Uterine prolapse: The uterus and cervix drop into the vaginal canal and may pass out of the opening. Uterine prolapse/pelvic organ prolapse is staged using a nationally recognized assessment tool (e.g. Bader-Walker Halfway Scoring or Pelvic Organ Prolapse Quantification system [POP-Q]).

Required Documentation

  • Non-Malignant indications for surgery

The patient’s Medical Record must include the following information:

  • Types of less invasive interventions or treatments the patient:
  • Has tried, or
  • Has not tolerated, or
  • Has a contraindication to, or
  • Has declined

NOTE: If the patient has declined less invasive alternatives to hysterectomy the rationale must be documented.

Coding

There are specific CPT codes for the different types of hysterectomy surgical procedures. (See Coding section)

Place of Service

The surgery may be performed in an inpatient or outpatient facility depending on the procedure type and any complicating medical conditions (comorbidities) of the patient.

Description

Hysterectomy is the surgical removal of the uterus, and sometimes the cervix. In some cases, a salpingo-oophorectomy, the surgical removal of the ovaries and fallopian tubes that connect the ovaries to the uterus, is done at the same time as the hysterectomy. The type of hysterectomy and the surgical approach depends on the diagnosis and the individual patient’s condition. In all cases, the woman will lose her ability to become pregnant and bear children. Depending on the condition, other less invasive treatments may be tried as an alternative to hysterectomy.

Indications for hysterectomy surgery may include but are not limited to the following conditions (1):

  • Abnormal or dysfunctional uterine bleeding
  • Cancer
  • Chronic pelvic pain or infection (e.g. Endometriosis, pelvic inflammatory diseases) not relieved by conservative treatment
  • Complications related to childbirth (e.g. Uterine rupture, intractable post-partum hemorrhage)
  • Gynecologic cancer prevention
  • Premalignant disease of the uterus, cervix, ovaries, fallopian tubes or endometrium
  • Symptomatic pelvic organ relaxation (e.g. Uterine prolapse, cystourethrocele, rectocele)
  • Symptomatic uterine leiomyomata (Fibroids)
  • Tubo-ovarian abscess

Procedure Types for Hysterectomy Surgery:

  • Radical hysterectomy: The uterus, cervix, ovaries, fallopian tubes, oviducts, lymph nodes, and lymph channels are removed.
  • Subtotal hysterectomy: The uterus alone is removed; the cervix is left in place.
  • Total hysterectomy: The uterus and cervix are removed. A bilateral salpingo-oophorectomy, removal of both fallopian tubes and ovaries, may also be performed.

Procedure Routes for Hysterectomy Surgery(2):

  • Abdominal hysterectomy: The surgeon opens the abdominal cavity with a 4 to 6-inch incision (which may be vertical or horizontal), cuts free the uterus, and in some cases, the ovaries and fallopian tubes, and removes the uterus & related structures through the opening in the abdomen.
  • Laparoscopic Hysterectomy: The surgeon uses a laparoscope and instruments inserted through small abdominal incisions to free the uterus. The uterus is removed through the vagina or abdomen.
  • Vaginal hysterectomy: The surgeon makes an incision through the top of the vagina and through this incision, cuts the uterus free. The uterus is removed through the vagina.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Benefit Application

N/A

Rationale

Hysterectomy is the second most frequently performed major surgical procedure for women of reproductive age in the United States, after cesarean section. (CDC http://www.cdc.gov/reproductivehealth/womensrh/hysterectomy.htm). The route of hysterectomy depends on the indication for surgery, size of the uterus and the size of the patient. Studies in the published literature support hysterectomy as an accepted method of medical practice/treatment only for specific conditions, in specific situations and only after alternative therapies have been attempted and failed.

Non-Malignant Indications for Hysterectomy Surgery

In 2000, Broder et al. published a study on the appropriateness of hysterectomy surgery recommended for non-emergency and non-oncologic indications. The report looked at 497 women who had a hysterectomy between August 1993 and July 1995 assessing the appropriateness of their surgery using criteria developed by a multispecialty expert physician panel and the ACOG criteria sets for hysterectomies. The results showed that the most common indications for hysterectomy were leiomyomata (60% of hysterectomies), pelvic relaxation (11%), pain (9%), and bleeding (8%). Three hundred sixty-seven (70%) of the hysterectomies did not meet the level of care recommended by the expert panel and were judged to be recommended inappropriately. ACOG criteria sets were applicable to 71 women, and 54 (76%) did not meet ACOG criteria for hysterectomy. The most common reasons recommendations for hysterectomies were considered inappropriate were lack of adequate diagnostic evaluation and failure to try alternative treatments before hysterectomy. The conclusion from the authors is that hysterectomy surgery is often recommended for indications judged to be inappropriate. The authors further recommend that In the absence of a life-threatening emergency (e.g., uterine hemorrhage) patients and physicians work together to ensure that a proper diagnostic evaluation has been done and appropriate alternative therapeutic treatments as well as the patient’s child bearing plans are considered before hysterectomy is recommended (1)

In 2005, Jacoby et al. reported on a cross sectional analysis of the 2005 Nationwide Inpatient Sample (NIS). All women aged 18 years or older who had a hysterectomy for a benign condition were included. The findings of the study showed that among 518,828 hysterectomies, 14% were laparoscopic, 64% abdominal and 22% vaginal. Women older than 35 years had lower rates of laparoscopic than abdominal (odds ratio [OR] 0.85, 95% confidence interval [CI]: 0.77-0.94 for age 45-49 years) or vaginal hysterectomy (OR 0.61, 95% CI: 0.540.69 for age 45-49 years). The odds of laparoscopic hysterectomy compared with abdominal hysterectomy were higher in the West than in the Northeast (OR 1.77, 95% CI: 1.2-2.62). African-American, Latina, and Asian women had 40%-50% lower odds of laparoscopic surgery compared with abdominal hysterectomy (P<.001). Women with low income, Medicare, Medicaid, or no health insurance were less likely to undergo laparoscopic surgery than either vaginal or abdominal hysterectomy (P<.001). Women with leiomyomas (P<.001) and pelvic infections (P<.001) were less likely to undergo laparoscopic than abdominal hysterectomy. Women with leiomyomas (P<.001), endometriosis (P<.001), or pelvic infections (P<.001) were more likely to have laparoscopic than vaginal hysterectomy. (3)

Hysterectomy is the most common treatment for symptomatic fibroids in the United States. The primary advantage is that by completely removing the uterus, there is little potential for fibroid recurrence. (4) In a multicenter, nonrandomized prospective study hysterectomy was compared to myomectomy and embolization for improving uterine fibroid-related symptoms and the effect on health-related quality of life. This study, despite showing all three therapies as extremely effective in reducing fibroid-related symptoms, demonstrated that two years after the surgery there was a significantly better health-related quality-of-life reported for patients treated with hysterectomy. However, many women who undergo hysterectomy later regret the loss of fertility or have concerns regarding their femininity (5-6)

Frequency of Hysterectomy Surgery

In 2007 Babalola et al. as well Jonsdottir et al. in 2011 reported that the frequency of hysterectomy appears to be decreasing, possibly due to the availability of less invasive therapies for management of conditions previously treated with hysterectomy. Between 1965 and 2002 combined hysterectomy procedures declined by 63%; this affected every age group except for individuals aged 75-85 year. The most common reasons noted for surgery were uterine leiomyomata (28%), precancerous conditions (23%), and genital prolapse at (12%). (7-8)

References

  1. Broder, MS, Kanouse DE, Mittman, BS, Bernstein SJ. The appropriateness of recommendations for hysterectomy. Obstet Gynecol 2000, 95:199. Available at URL: http://www.ncbi.nlm.nih.gov/pubmed/10674580. Last accessed April, 2015.
  2. ACOG Committee Opinion 444. Choosing the route of hysterectomy for benign disease. Obstetrics and Gynecology 2009; 114(5):1156-8. DOI: 10.1097/AOG.0b013e3181c33c72.
  3. Jacoby VL, Autry A, Jacobson G, et al. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol 2009; 114:1041.
  4. Hutchins FL Jr. Uterine fibroids. Diagnosis and indications for treatment, Obstet Gynecol Clin North Am. 1995 Dec; 22(4):659-65.
  5. Bachmann GA, Bahouth LA, Amalraj P, et al. Uterine fibroids: Correlations of aneamia and pain to fibroid location and uterine weight. Journal of Reproductive Medicine 2011, 56(11-12); 463-466.
  6. Burke CT, Ray CE Jr, Lorenz JM, et al. Expert Panel on Interventional Radiology. ACR Appropriateness Criteria® radiologic management of uterine leiomyomas. [Online publication]. Reston (VA): American College of Radiology (ACR); 2012. Available at URL: http://guideline.gov/content.aspx?f=rss&id=37946&osrc=12. Last accessed April, 2015.
  7. Babalola EO, Bharucha AE, Schleck CD, et al. Decreasing utilization of hysterectomy: a population-based study in Olmsted County, Minnesota, 1965-2002. Am J Obstet Gynecol 2007; 196:214.e.
  8. Jonsdottir GM, Jorgensen S, Cohen SL, et al: Increasing minimally invasive hysterectomy: Effect on cost and complications. Obstet Gynecol 2011; 117:1142-1149.

Additional resources and websites:

  1. Altman, D et al. Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study. The Lancet, Oct. 27, 2007; vol 370: pp. 1494-1499.
  2. Fayed, L. Hysterectomy side effects: What to expect after a hysterectomy. Updated May 3, 2012. Available at URL address: http://cancer.about.com/od/uterinecancer/a/Hysterectomy-Side-Effects.htm. Last accessed April, 2015.
  3. Hysterectomy. (2012) Retrieved from: http://women.webmd.com/guide/hysterectomy. Last accessed April, 2015.
  4. Jones III, H.W. Chapter 71 Gynecologic surgery in. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice 19th edition. Munro MG, Critchley HOD, Fraser IS. The FIGO systems for nomenclature and classifications of causes of abnormal uterine bleeding in the reproductive years: Who needs them? Am Jrnl of OB and Gyn 2012, 207 (4); 259-265.
  5. Persu C, Chapple CR, et al. Pelvic organ prolapse quantification system (POP-Q) – A new era in pelvic prolapse staging. Jrnl of Med and Life 2011, 4 (1); 75-81.
  6. U.S. Department of Health and Human Services, Office on Women’s Health, Hysterectomy – Frequently Asked Questions. Available at URL address: http://www.womenshealth.gov/publications/our-publications/fact-sheet/hysterectomy.pdf. Last accessed April, 2015.

Coding

Codes

Number

Description

CPT

58150

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)

 

58152

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch)

 

58180

Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)

 

58260

Vaginal hysterectomy, for uterus 250 grams or less

 

58262

Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s), and/or ovary(s)

 

58263

Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s), and/or ovary(s), with repair of enterocele

 

58267

Vaginal hysterectomy, for uterus 250 grams or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

 

58270

Vaginal hysterectomy, for uterus 250 grams or less; with repair of enterocele

 

58275

Vaginal hysterectomy, with total or partial vaginectomy

 

58280

Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele

 

58290

Vaginal hysterectomy, for uterus greater than 250 grams

 

58291

Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)

 

58292

Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s), with repair of enterocele

 

58293

Vaginal hysterectomy, for uterus greater than 250 grams; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

 

58294

Vaginal hysterectomy, for uterus greater than 250 grams; with repair of enterocele

 

58541

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

 

58542

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

 

58543

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g

 

58544

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

 

58550

Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 grams or less

 

58552

Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 grams or less with removal of tube(s) and/or ovary(s)

 

58553

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams

58554

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)

 

58570

Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less

 

58571

Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less; with removal of tube(s) and/or ovary(s)

 

58572

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250g

 

58573

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250g; with removal of tube(s) and/or ovary(s)

ICD-9 Procedure Codes

68.31

Laparoscopic supracervical hysterectomy (LSH)

 

68.39

Other and unspecified subtotal abdominal hysterectomy

 

68.41

Laparoscopic total abdominal hysterectomy

 

68.49

Other and unspecified total abdominal hysterectomy

 

68.51

Laparoscopically assisted vaginal hysterectomy (LAVH)

 

68.59

Other and unspecified vaginal hysterectomy

ICD-9-CM Diagnosis Codes

154.0

Malignant neoplasm of rectosigmoid junction

 

179

Malignant neoplasm of uterus, part unspecified

 

180.0 - 180.9

Malignant neoplasm of cervix uteri

 

181

Malignant neoplasm of placenta

 

182.0 - 182.8

Malignant neoplasm of body of uterus

 

183.0 - 183.9

Malignant neoplasm of ovary and other uterine adnexal

 

184.8

Malignant neoplasm of other specified sites of female genital organs

 

198.6

Secondary malignant neoplasm of ovary

 

218.0 - 218.9

Uterine leiomyoma

 

219.0 - 219.9

Other benign neoplasm of uterus

 

220

Benign neoplasm of ovary

 

221.0 - 221.9

Benign neoplasm of other female genital organs

 

233.1 - 233.39

Carcinoma in situ of breast and genitourinary system

 

235.4

Neoplasm of uncertain behavior of retroperitoneum and peritoneum

 

236.0

Neoplasm of uncertain behavior of uterus

 

236.1

Neoplasm of uncertain behavior of genitourinary organs, placenta

 

236.2

Neoplasm of uncertain behavior of ovary

 

236.3

Neoplasm of uncertain behavior of other and unspecified female genital organ

 

239.5

Neoplasm of unspecified nature of other genitourinary organs

 

456.5

Pelvic varices

 

614.6

Pelvic peritoneal adhesions, female (postoperative) (postinfection)

 

614.9

Unspecified inflammatory disease of female pelvic organs and tissues

 

617.0 - 617.9

Endometriosis

 

618.00 - 618.9

Genital prolapse

 

620.0 - 620.9

Noninflammatory disorders of ovary, fallopian tube, and broad ligament

 

621.33

Endometrial hyperplasia with atypia

 

621.6

Malposition of uterus

 

622.10

Dysplasia of cervix; unspecified

 

622.11

Mild dysplasia of cervix

 

622.12

Moderate dysplasia of cervix

 

625.0 - 625.9

Pain and other symptoms associated with female genital organs

 

626.2

Excessive or frequent menstruation

 

626.4

Irregular menstrual cycle

 

626.6

Metrorrhagia

 

626.8

Other disorder of menstruation and other abnormal bleeding from female genital tract

 

626.9

Unspecified disorder of menstruation and other abnormal bleeding from female genital tract

 

627.0

Premenopausal menorrhagia

 

627.1

Postmenopausal bleeding

 

627.8

Other specified menopausal and postmenopausal disorder

 

627.9

Unspecified menopausal and postmenopausal disorder

 

666.04 - 666.34

Postpartum hemorrhage

 

752.32 – 752.39

Other congenital anomaly of uterus

 

795.00

Abnormal glandular Papanicolaou smear of cervix

 

795.01

Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US)

 

795.02

Papanicolaou smear of cervix with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H)

 

795.09

Other abnormal Papanicolaou smear of cervix and cervical HPV

Type of Service

Surgery

 

Place of Service

Inpatient Outpatient

 

Appendix

N/A

History

Date

Reason

02/11/13

New policy. Add to surgery classification. This policy is approved with a 90-day hold for provider notification and will be effective on May 19, 2013.

02/22/13

Policy Guidelines updated; clarified documentation requirements for non-malignant indications to support medical necessity.

04/02/13

Policy guidelines revised with the MCG modifications diagnoses sorted alphabetically for ease of use. Reference 1 updated to 17th Ed. of MCG.

04/17/13

Update Related Policies. Change title to 7.01.109.

07/18/13

Update Related Policies. Delete 4.01.17 as it was archived.

09/09/13

Replace Policy. Under malignant indications heading - Policy statement added that “In situations where clinical features are highly suspicious for malignancy (one example is a mass suspicious for ovarian cancer) “Added related policy IMRT-Abdomen/Pelvis. Policy guidelines wording clarified about the plan-specific additions and modifications to the proprietary MCG™ criteria. Policy statement changed as noted.

02/10/14

Annual Review. Policy reviewed. Policy guidelines revised with a modification to MCG™ that includes medically necessary criteria for pelvic pain and/or dysmenorrhea. No references added. Policy statement unchanged. CPT codes 58200, 58210, 58240, 58285, 58548, 58951-59525; and ICD-9 procedure codes 68.61 and 68.71 removed from the policy; these were provided for informational purposes only.

06/09/14

Interim Update. Policy extensively re-written. Policy statements reorganized for usability. Policy updated with literature search through April 2014. Reference to using MCG as a tool to guide determinations is removed. Added definitions to Policy Guidelines. Removed documentation requirement for a gyn-oncology consult for the diagnosis of choriocarcinoma. Removed documentation requirement to confirm the patient understands a hysterectomy is permanent sterilization. Additional resources and websites 5, 7 added; others renumbered/removed. Policy statements reorganized as noted, intent is unchanged.

10/23/14

Update Related Policies. Add 7.01.557.

12/22/14

Interim Update. Policy reviewed. Clarifying edits to Policy statements for non-malignant indications that patient can refuse alternative interventions if documented in the medical record. Definition of Terms revised. Reference 6 removed from the additional resources and websites section; others renumbered. Policy statements changed as noted.

05/12/15

Annual Review. Policy updated with literature search through March 2014. Policy criteria changed to state that non-malignant indications include symptoms 1 or more days per month that interfere with ADLS in place of 1 or more days per week. Added fibroid UAE as an example of a uterine sparing procedure. Fibroid embolization added to Definition of Terms. No references added. Policy statement changed as noted.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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