ModifiedSelectHealthPolicy 675

Dynamic Spectral Imaging Smart Colposcopy (DYSIS)

SelectHealth policy describing coverage determination for use of DYSIS computer-aided colposcopy (dynamic spectral imaging and pseudo-color imaging) for evaluation of the cervix; applies to SelectHealth Commercial, Medicare, and Community Care (Medicaid) plans as described.

Policy Summary

PayerSelectHealth

PolicyDynamic Spectral Imaging Smart Colposcopy (DYSIS)

Policy CodePolicy 675

Change TypeMaterial coverage and criteria updates (added exclusionsexpanded gene list)

Effective DateOct 4, 2023

Next Review DateOct 16, 2025

Key ActionVerify member benefits and obtain prior authorization when required; note CPT 57465 (DYSIS) is not covered for Commercial and CHIP plans.

SourceLink

POLICY UPDATE CHANGES

For Commercial Plan Policy, added the OVERA (MIA2G) and Risk of Ovarian Malignancy Algorithm (ROMA) tests to list of excluded tests.

For Commercial Plan Policy, updated breast and ovarian cancer susceptibility genes listed in criterion #2 to include (ATM, BRCA1, BRCA2, BRIP1, Lynch syndrome genes [MLH1, MSH2, MSH6, EPCAM], PALB2, RAD51C, and RAD51D).

For Commercial Plan Policy, added the PMS2 gene to list of eligible susceptibility genes in criterion #2.

1Not-covered CPT codes

3Biomarker tests excluded (Commercial)

follow CMSMedicare guidance

58353/58356/58563

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered CPT codes for ablation

≥51Age rule for oophorectomy

115+Documented refs cited

Coverage Criteria

inv-01: Coverage by Plan

Coverage determinations vary by plan:

Commercial/CHIP: Select Health does not cover dynamic spectral imaging smart colposcopy (DYSIS) because the technology lacks specificity and is considered experimental/investigational.

Commercial and CHIP plans follow this stance.

Medicare: Coverage is determined by CMS; if CMS has not adopted a determination and InterQual is not available, the Select Health Commercial policy applies.

Providers should consult CMS coverage database for current Medicare guidance.

Community Care (Medicaid): Select Health Community Care typically aligns with State of Utah Medicaid policy and may use InterQual; in some situations NCD/LCD or Select Health commercial policy may be applied.

Providers should consult Utah Medicaid resources for current guidance.

inv-02: Covered indications

Covered: For the indications listed above (endometrial ablation for heavy menstrual bleeding/dysfunctional uterine bleeding).

Coverage condition: Procedure corresponds to a covered CPT code (58353, 58356, or 58563) and is performed for indicated diagnoses such as menorrhagia/dysfunctional uterine bleeding.

Document clinical indication and bill the appropriate covered CPT code.

inv-03: Investigational procedures

Not covered / Investigational

Noncoverage condition: Procedures coded with CPT 0071T or 0072T (focused ultrasound ablation of uterine leiomyomata) are considered investigational/unproven for this indication and are not covered.

Listed explicitly as investigational/unproven for this indication.

inv-04: Covered indications and required supporting conditions

SelectHealth considers hysterectomy medically necessary when ANY one of the following broad criterion groups is met (follow detailed subcriteria below):

Primary covered indications: Cancer or high cancer risk (e.g., EIN, persistent CIN >6 months after excision, endocervical adenocarcinoma in situ, endometrial cancer, ovarian/tubal cancer by imaging, tubal cancer by imaging, Lynch/BRCA/RAD51C/D mutations, gestational trophoblastic disease, uterine sarcoma).

See policy oncology-related criteria for specifics.

Abnormal uterine bleeding (AUB) - Pre-menopausal: All of: (a) Hormonal therapy for at least 12 weeks (or documented contraindication/intolerance/ineffectiveness); AND (b) Conservative surgery cannot be used because contraindicated, failed, or inappropriate; AND (c) Ultrasound performed and if abnormal then endometrial biopsy or hysteroscopy required for patients under 44; for age 44 or older endometrial biopsy or hysteroscopy is required.>= 12 weeks for hormonal therapy where specified

Document prior therapies and diagnostic evaluations.

Abnormal uterine bleeding (AUB) - Post-menopausal:

inv-05: Oophorectomy criteria

Oophorectomy coverage when performed with hysterectomy is allowed when ANY of the following are met:

Oophorectomy allowed reasons: Endometrial cancer present; OR ovarian pathology present; OR patient ≥ 51 years with average risk of ovarian cancer; OR increased risk due to genetic mutations or family/personal history (including specified susceptibility genes: ATM, BRCA1, BRCA2, BRIP1, Lynch genes [MLH1, MSH2, MSH6, EPCAM, PMS2], PALB2, RAD51C, RAD51D); OR known familial cancer syndrome after completion of childbearing; OR other listed clinical reasons (infertility, PCOS, endometriosis, age ≥45 with current smoking, breast cancer treatment considerations).>= 51 for average-risk age criterion

See policy for full genetic and family-history specifics.

inv-06: Salpingectomy

Salpingectomy coverage statement:

Salpingectomy: SelectHealth covers salpingectomy performed with hysterectomy for patients at any age.

No age restriction when performed concomitantly with hysterectomy.

inv-07: Coverage decision hierarchy

Coverage is determined as follows depending on plan type and available external criteria:

Coverage source logic: If CMS has an applicable determination, CMS criteria govern for Medicare members; if CMS has no determination and InterQual criteria are available, InterQual applies; if neither CMS nor InterQual criteria are available, SelectHealth Commercial policy applies.

Applies to Medicare/Commercial decision hierarchy and may affect prior authorization and review processes.

inv-08: Laparoscopic RFA — Medical Necessity

Covered when ALL of the following are met

Laparoscopic RFA candidacy: 1) Ultrasound evidence of uterine fibroids with maximal diameter less than 10 cm; AND 2) Member desires uterine-sparing treatment or is contraindicated for hysterectomy; AND 3) Member has at least one fibroid-related symptom (menorrhagia causing activity limitation or anemia; pelvic pain/pressure; lower back pain; urinary symptoms from bladder compression; or gastrointestinal symptoms from bowel compression).fibroid size < 10 cm

Document ultrasound measurements, symptom attribution to fibroids, and patient preference or contraindication to hysterectomy.

inv-09: Age requirement

Additional requirement

Age: Patient age 18 years or older.>= 18

Applies to Commercial Plan and CHIP.

inv-10: LUNA / PSN — Not covered (experimental/investigational)

LUNA and PSN: Select Health does NOT cover laparoscopic uterine nerve ablation (LUNA) or presacral neurectomy (PSN) because current evidence deems these treatments experimental/investigational.

Policy references systematic review and guideline conclusions that LUNA/PSN are not efficacious.

inv-11: Indications permitting induction prior to 39 weeks

Covered when ANY ONE of the following medical indications is documented for Commercial and CHIP plans:

Indication list: Placenta abruption; OR placenta previa; OR PROM; OR chorioamnionitis; OR maternal medical indications (including preeclampsia with BP ≥140/90, severe preeclampsia/HELLP, eclampsia, coagulation defects, diabetes, chronic renal disease, antiphospholipid syndrome, SLE with comorbidity, prior classical incision or myomectomy, gestational or chronic hypertension [BP ≥140/90], liver/biliary disease, intrahepatic cholestasis with supporting labs/medication documentation, HIV with viral load >1000 and intact membranes, maternal cardiac disease, alloimmunization/Rh sensitization, maternal-fetal hemorrhage, prior uterine rupture, other moderate to severe maternal conditions with MFM approval); OR fetal indications (fetal growth restriction <10th percentile, oligohydramnios AFI ≤5 or DVP <2, polyhydramnios AFI >30, multiple gestation, abnormal antenatal testing, fetal demise, previous stillbirth, severe congenital anomalies, unstable lie >38 weeks, fetal damage from exposure, abnormal umbilical artery, alloimmunization, or other documented fetal indications with MFM consult).ANY one met

Documentation required where noted (BP readings, AFI/DVP, growth percentiles, viral load); MFM consultation required for some items.

inv-12: General coverage criteria

Covered when ALL of the following are met

General coverage principle: Elective (non–medically indicated) delivery prior to 39 weeks is discouraged; delivery before 39 weeks is acceptable only when a recognized maternal, fetal, or placental complication that justifies earlier delivery is documented and gestational age is accurately determined.gestational age < 39 weeks requires documented indication

Providers must individualize decisions and document indications and gestational age determination.

inv-13: Examples of medical indications

Examples of medical indications that may justify early delivery (not exhaustive):

Accepted indications (examples): Abnormal antenatal testing; fetal demise; previous stillbirth; severe congenital anomalies; unstable lie (>38 weeks); fetal damage from radiation/drug/virus exposure; abnormal umbilical artery; alloimmunization; and other documented indications with MFM consultation noted.documentation and, when indicated, MFM consultation

List is illustrative, not exhaustive; documentation and MFM consult may be required.

inv-14: Investigational / Not covered

Select Health Commercial and CHIP policy position

Excluded tests: Select Health does NOT cover the OVA1, OVERA (MIA2G), or ROMA tests due to lack of clinical data and absence of FDA recommendation for use as a screening tool; these meet the plan's definition of experimental/investigational.

Commercial plan exclusion; investigational/unproven.

inv-15: Coverage indications for prophylactic oophorectomy/salpingo-oophorectomy

Covered when AT LEAST ONE of the following is present:

Coverage indications: Endometrial cancer present; OR a confirmed genetic mutation on molecular testing in breast/ovarian cancer susceptibility genes (ATM, BRCA1, BRCA2, BRIP1, Lynch genes [MLH1, MSH2, MSH6, EPCAM, PMS2], PALB2, RAD51C, RAD51D); OR known familial cancer syndrome associated with increased ovarian cancer risk after completion of childbearing; OR premenopausal woman with ER+ and/or PR+ breast cancer.at least one required

See policy for full list and timing considerations (e.g., completion of childbearing).

SelectHealth considers dynamic spectral imaging smart colposcopy (DYSIS) and the associated CPT 57465 to be experimental/investigational and does not cover these services under the Commercial plan and CHIP because the technology lacks sufficient specificity for colposcopic evaluation.

Focused ultrasound ablation of uterine leiomyomata (reported with CPT 0071T and 0072T) is considered investigational/unproven for this indication and is not covered by SelectHealth.

Inclusion or exclusion of a procedure, diagnosis, or device code in this policy does not itself constitute or imply member coverage or provider reimbursement; coverage is determined by the member's individual benefit plan in effect at the time services are rendered and should be verified prior to service.

SelectHealth does NOT cover hysterectomy for indications that are not explicitly described in this medical policy; such procedures are considered not medically necessary unless they meet the policy's listed medical necessity criteria.

The Food and Drug Administration recommends that the use of laparoscopic power morcellators is contraindicated when the tissue to be morcellated is known or suspected to contain malignancy; SelectHealth follows this guidance and expects that morcellation not be used in these circumstances.

Laparoscopic techniques of myolysis outside the documented indication — including procedures such as MRI laser ablation, cryomyolysis, or laser ablation using bipolar needles — are considered experimental/investigational and are not covered by SelectHealth.

Elective induction of labor prior to 39 weeks gestation without documentation of one of the policy's listed medical indications is not covered. Elective inductions before 39 weeks may increase neonatal risk and therefore require a documented qualifying indication to be considered for coverage.

Suspected fetal macrosomia or documentation of fetal lung maturity alone does not constitute an indication for early-term delivery and, by itself, is not an acceptable justification for delivery prior to 39 weeks under this policy.

SelectHealth does NOT cover the OVA1, OVERA (MIA2G), and ROMA biomarker tests for the stated indications on the Commercial plan and CHIP; these assays are considered investigational/unproven and are excluded from coverage.

Listing or inclusion of codes in this policy does not guarantee member coverage or provider reimbursement. Benefits and eligibility are determined by the member's individual contract and must be verified with the member's plan prior to service.

The inclusion or exclusion of codes within this policy does not itself determine coverage; coverage decisions must be confirmed by reviewing the member's individual benefit plan and obtaining any required prior authorization.

Hysterectomy performed for indications other than those explicitly listed in this policy is considered not medically necessary and will not be covered unless the member meets one of the policy's specified indications.

Per FDA safety communications, laparoscopic power morcellators should be contraindicated when tissue to be morcellated is known or suspected to contain malignancy. SelectHealth aligns with this recommendation and considers morcellation inappropriate in that context.

Laparoscopic uterine nerve ablation (LUNA) and presacral neurectomy (PSN) are considered experimental/investigational by SelectHealth and therefore are not covered for the treatment of chronic pelvic pain or related indications.

Elective induction of labor prior to 39 weeks gestation is considered not medically necessary unless documentation demonstrates one of the policy's listed medical indications; absent such documentation, elective early-term delivery may be denied.

Non‑medically indicated (elective) early‑term deliveries before 39 weeks are considered not medically necessary and will not be covered unless a documented medical indication justifies the earlier delivery.

Use of OVA1 and similar multibiomarker assays is not recommended as a stand‑alone diagnostic test or screening tool; these tests have limited evidence for use outside specific preoperative settings and are not supported as solitary diagnostic measures.

This policy is informational and does not replace clinical judgment. It should not be relied upon as medical advice for diagnosis or treatment decisions for individual patients; providers must use clinical judgment and consult appropriate resources for individual patient care.

Coding

Not covered / Experimental CPT CodesCPTNot Covered

57465

Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (list separately in addition to code for primary procedure)

Covered CPT CodesCPTCovered

58353	Endometrial ablation, thermal without hysteroscopic guidance
58356	Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed
58563	Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation)

Investigational / Not Covered for this indicationCPTNot Covered

0071T	Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue
0072T	Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue

HCPCS CodesHCPCS

No codes listed

Policy coding notesmixed

CPT copyright notice appears in policy

No explicit codes in this sectionmixed

No codes listed

Hysterectomy and related CPT CodesCPT

45560	Repair of rectocele (separate procedure)
57250	Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
57260	Combined anteroposterior colporrhaphy
57265	Combined anteroposterior colporrhaphy; with enterocele repair
57280	Colpopexy, abdominal approach
57282	Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)
57283	Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy)
57425	Laparoscopy, surgical, colpopexy
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 (eg, Marshall-Marchetti-Krantz, Burch)

1–10 of 37

1/4

HCPCS CodesHCPCS

No codes listed

Covered CPT CodesCPTCovered

58674

Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency

Procedure CPT Codes (unlisted)CPT

49329	Unlisted laparoscopy procedure, abdomen, peritoneum and omentum
58578	Unlisted laparoscopy procedure, uterus

HCPCS CodesHCPCS

C1886

Catheter, extravascular, tissue ablation, any modality (insertable)

CPT CODESCPT

59400	Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care.
59409	Vaginal delivery only (with or without episiotomy and/or forceps).
59410	Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care.
59510	Routine obstetric care including antepartum care, cesarean delivery, and postpartum care.
59514	Cesarean delivery only.
59515	Cesarean delivery only; including postpartum care.
59525	Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure).
59612	Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps).
59614	Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care.
59610	Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery.

HCPCSHCPCS

No codes listed

CPT Codes referencedCPT

81500	Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score
81503	Oncology (ovarian), biochemical assays of five proteins (CA-125, apolipoprotein A1, beta-2 microglobulin, transferrin, and pre-albumin), utilizing serum, algorithm reported as a risk score
84999	Unlisted chemistry procedure

HCPCS CodesHCPCS

No codes listed

Covered CPT CodesCPTCovered

58661	Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
58720	Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
58940	Oophorectomy, partial or total, unilateral or bilateral
58943	Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy

HCPCS CodesHCPCS

No codes listed

HCPCS CodesHCPCS

No codes listed

inv-52: Conservative therapy duration — ≥ 12 weeks for multiple indications (hormonal therapy, NSAIDs, LNG-IUS, GnRH agonist, tranexamic acid) where specified.

Conservative therapy duration≥ 12 weeks of appropriate medical therapy (e.g., hormonal therapy, LNG-IUS, GnRH agonist, tranexamic acid, NSAIDs) required where specified before surgical hysterectomy or other definitive procedures unless contraindicated or not tolerated

Documentation expectationsRecord trial duration and reason for discontinuation (contraindication, intolerance, ineffectiveness) when conservative therapy <12 weeks

Applicability

Provider Actions & Billing Instructions

Denial Risk

Prior authorization — DYSIS (CPT 57465)

SelectHealth requires prior authorization for Dynamic Spectral Imaging smart colposcopy (DYSIS, CPT 57465). Under SelectHealth Commercial and CHIP benefit plans this technology is considered experimental/investigational and is not covered; prior authorization would not render investigational services payable.

Affected code: CPT 57465 (Computer-aided mapping of cervix uteri during colposcopy)
Claims for DYSIS are at risk of denial under Commercial and CHIP plans

Billing Rule

Code-specific coverage summary

Endometrial ablation procedures should be billed using the covered CPT codes that correspond to the service performed. Codes listed as investigational or not covered must not be used as the primary billing code for an ablation.

Background

Dynamic Spectral Imaging (DYSIS) with Pseudo-Color Imaging (PCI) is a computer‑aided colposcopy system that images the cervix and produces a color‑coded map quantifying the acetowhitening response. PCI is described as an adjunctive imaging feature and should not replace a complete colposcopic examination or directed biopsy when clinically indicated.

Definitions

inv-106: DYSIS / PCI — DYSIS with Pseudo-Color Imaging (PCI): a digital colposcope that images the cervix and lower genital tract and displays areas of acetowhitening.

DefinitionDYSIS with Pseudo-Color Imaging (PCI) is a digital colposcope that images the cervix and lower genital tract and displays areas of acetowhitening as a color-coded map based on proprietary software quantification

Clinical rolePCI is described as an adjunctive imaging feature and should not replace a complete colposcopic examination

Use caseIntended to support evaluation of abnormal Pap smears and guide directed biopsy during colposcopy

inv-107: Global ablative techniques — Non-hysteroscopic methods that ablate the endometrium using modalities such as bipolar radiofrequency, heated fluid (balloon), microwave, etc.

DefinitionGlobal ablative techniques: non-hysteroscopic methods that ablate the endometrium using modalities such as bipolar radiofrequency, heated fluid (balloon), microwave, hydrothermal, cryotherapy, and laser

Revision History

2023-12-01addedLatest

For the Commercial plan policy, added the PMS2 gene to the list of eligible breast/ovarian cancer susceptibility genes in criterion #2.

2023-11-13revised

For the Commercial plan policy, updated the list of breast and ovarian cancer susceptibility genes in criterion #2 to include ATM, BRCA1, BRCA2, BRIP1, Lynch syndrome genes (MLH1, MSH2, MSH6, EPCAM), PALB2, RAD51C, and RAD51D.

2023-09-01added

Policy Summary

PayerSelectHealth

PolicyDynamic Spectral Imaging Smart Colposcopy (DYSIS)

Policy CodePolicy 675

Change TypeMaterial coverage and criteria updates (added exclusionsexpanded gene list)

Effective DateOct 4, 2023

Next Review DateOct 16, 2025

Key ActionVerify member benefits and obtain prior authorization when required; note CPT 57465 (DYSIS) is not covered for Commercial and CHIP plans.

SourceLink

On This Page

All of: normal vaginal and cervical exam; endometrial biopsy completed; and no improvement with stopping/changing hormones for at least 3 months (documentation required).

Post-menopausal AUB pathway.

Postpartum bleeding: Either life-threatening postpartum bleeding within 48 hours OR bleeding ≥48 hours with retained products of conception plus failure of indicated treatments (uterine massage, manual extraction, D&C, balloon tamponade) and failure of two uterotonic medications.

Document interventions and medication trials.

Adenomyosis: Clinical history/exam consistent with adenomyosis with failure of NSAIDs >12 weeks (if tolerated) AND failure of at least one of: hormone therapy >12 weeks, LNG-IUS >12 weeks, tranexamic acid >12 weeks, GnRH agonist >12 weeks, or uterine artery embolization.>= 12 weeks for conservative therapies

Document prior medical and less invasive interventions.

Pelvic pain/dysmenorrhea/dyspareunia: All of: pain persists despite NSAIDs >12 weeks (unless contraindicated); other GI/GU/musculoskeletal/gynecologic causes excluded; psychiatric disorder excluded or well-managed; imaging or diagnostic laparoscopy within 2 years nondiagnostic; AND trial of appropriate therapies per clinical circumstance (e.g., hormone therapy >12 weeks for endometriosis).>= 12 weeks for NSAIDs/hormonal trials

Require documented diagnostic workup and treatment history.

Uterine leiomyomas (fibroids): Both: (i) leiomyomas not amenable to hysteroscopic treatment; AND (ii) at least one of: abnormal bleeding due to fibroids; uterine size doubled on ultrasound in 1 year; hydronephrosis/organ compression symptoms; or pelvic pain/dyspareunia with other causes excluded.

Ultrasound and symptom documentation required.

Endometriosis with uterine involvement: Laparoscopically confirmed endometriosis with uterine involvement and failure of one of GnRH agonist/antagonist, danazol, LNG-IUS, or hormone therapy for >12 weeks within the last 5 years.>= 12 weeks for listed therapies

Document laparoscopic diagnosis and prior therapies.

Uterine prolapse: Either symptomatic apical descent ≥50% total vaginal length OR symptomatic anterior wall stage III (stage II/III criteria per POP-Q) with genital hiatus ≥4 cm on Valsalva; AND conservative treatments discussed and surgical plan includes apex support (e.g., colpopexy).

POP-Q staging criteria and documentation required.

Infection: Either chronic PID (pelvic pain, ≥2 acute PID episodes or persistent antibiotics, and infection documented by culture) OR tubo-ovarian abscess by imaging with ectopic excluded and signs/symptoms and failure/worsening despite IV antibiotics.

Document cultures, imaging, and treatment response.

Applies to premenopausal abnormal uterine bleeding, adenomyosis, pelvic pain/endometriosis, and other indications listing conservative-therapy prerequisites

inv-53: Age threshold for oophorectomy with average risk — ≥ 51 years.

Age thresholdOophorectomy may be covered when patient is ≥ 51 years with average ovarian cancer risk

ContextApplies when performed with hysterectomy under the oophorectomy criteria

ExceptionsYounger patients may qualify based on genetic mutation, family history, or other listed high-risk conditions

inv-54: Fibroid maximum diameter on ultrasound — < 10 cm.

Maximum fibroid diameter (US)Fibroid(s) must be < 10 cm in maximum diameter on ultrasound for laparoscopic RFA candidacy

Procedure contextApplies to laparoscopic radiofrequency ablation (RFA) as specified in RFA medical necessity criteria

Counseling noteReproductive outcomes after RFA are limited; counsel patients desiring future fertility

inv-55: Blood pressure threshold for preeclampsia/gestational hypertension — ≥ 140/90.

Blood pressure thresholdPreeclampsia/gestational hypertension defined as blood pressure ≥ 140/90 (with ≥1+ proteinuria for preeclampsia)

Associated conditionsSevere preeclampsia includes HELLP and eclampsia is listed separately as indications for earlier delivery

DocumentationRecord BP values and proteinuria or severity markers when using this indication for induction prior to 39 weeks

inv-56: Oligohydramnios amniotic fluid index (AFI) threshold — AFI ≤ 5 cm or DVP < 2.

Oligohydramnios AFI/DVP thresholdOligohydramnios defined as AFI ≤ 5 cm or maximum vertical pocket (DVP) < 2 cm

Documentation requiredUltrasound AFI or DVP measurement must be included when claiming this indication for induction prior to 39 weeks

Relation to delivery timingOligohydramnios is a listed fetal indication that may justify induction before 39 weeks when documented

inv-57: Polyhydramnios AFI threshold — AFI > 30 cm.

Polyhydramnios AFI thresholdPolyhydramnios defined as AFI > 30 cm

Documentation requiredUltrasound AFI measurement must be provided when using this indication for induction before 39 weeks

Policy contextListed as a fetal indication that may permit early delivery under Commercial/CHIP criteria

inv-58: Fetal growth restriction threshold — < 10th percentile.

Fetal growth restriction thresholdFetal growth restriction defined as estimated fetal size < 10th percentile

DocumentationProvide growth percentile documentation when claiming induction or early delivery for fetal growth restriction

Use in decision-makingFGR is an accepted fetal indication permitting induction prior to 39 weeks when appropriately documented

inv-59: HIV viral load threshold for indication — > 1000 copies with intact membranes.

HIV viral load thresholdHIV with viral load > 1000 copies and intact membranes is a maternal indication for earlier delivery

Clinical noteWell-managed HIV (viral load ≤1000 or undetectable) may be term-managed; document viral load and membrane status

Documentation requiredInclude recent viral load testing and membrane status in records when using this indication

inv-60: OVA1 cutoffs — >= 5.0 premenopausal; >= 4.4 postmenopausal.

OVA1 cutoffs (OvaCalc)OVA1 numeric risk index cutoffs: ≥ 5.0 for premenopausal women; ≥ 4.4 for postmenopausal women

Assay componentsOVA1 combines five biomarkers (apolipoprotein A1, beta-2 microglobulin, CA-125, transferrin, transthyretin) into a 0.0–10.0 index via OvaCalc

Policy stanceDespite FDA-cleared use in adnexal mass assessment, SelectHealth Commercial/CHIP lists OVA1 as not covered for the stated indication

Covered CPT codes: 58353, 58356, 58563
Not covered / investigational for this indication: 0071T, 0072T

Prior Authorization

Prior authorization determined by benefit plan

Coverage and prior authorization requirements are determined by the member's benefit plan at the time of service. Providers must verify member benefits and authorization rules before rendering services.

Verify member-specific benefits and eligibility prior to services
Prior authorization requirements vary by plan and service

Documentation Required

Medical necessity required for coverage

Services will be covered only when the documented clinical presentation meets the policy's medical necessity criteria. For surgical procedures (e.g., hysterectomy, oophorectomy, RFA) documentation must show the applicable indication and that conservative therapies were tried when required.

Medical necessity documentation required for coverage decisions
Provide clinical records showing indication and prior therapies when applicable

Prior Authorization

Prior authorization requirement for listed CPT codes

The CPT codes listed in each clinical policy block are subject to prior authorization per the member's plan. For example, hysterectomy/oophorectomy and laparoscopic RFA related CPT codes require following SelectHealth (or CMS/InterQual when applicable) coverage criteria and authorization procedures.

Examples of CPTs subject to authorization: hysterectomy/oophorectomy codes, CPT 58674 for RFA
Follow SelectHealth or applicable CMS/InterQual criteria when requesting authorization

Prior Authorization

Prior authorization for laparoscopic RFA

When laparoscopic radiofrequency ablation (CPT 58674) is being considered, prior authorization may be required depending on the member's benefit plan. When applicable, ensure documentation supports the RFA criteria (e.g., ultrasound evidence of fibroids < 10 cm, uterine preservation desire or contraindication to hysterectomy, symptomatology).

Affected code: CPT 58674
Required documentation: ultrasound findings (fibroid size), symptom details, patient preference or contraindication to hysterectomy

Prior Authorization

Prior authorization and indication requirement

Elective induction of labor prior to 39 weeks (Commercial/CHIP) is covered only when at least ONE of the listed medical indications is present and documented (e.g., placental abruption, severe preeclampsia, PROM, fetal growth restriction). Documentation of the specific indication (and MFM consult when required) must be included with any authorization request.

Coverage for elective early induction prior to 39 weeks requires documentation of one qualifying medical indication
If 'other' maternal/fetal indications are used, document indication and include MFM consultation name when required

Note

Medicare/Medicaid coverage determination note

For Medicare members, coverage is determined by CMS. If CMS has not adopted a coverage determination and InterQual criteria are unavailable, SelectHealth Commercial policy may apply. For Medicaid members, state Medicaid (SelectHealth Community Care) policy typically applies; InterQual or NCD/LCD may be used in some cases.

Medicare: follow CMS NCD/LCD; if none, SelectHealth Commercial or InterQual may apply
Medicaid: follow state Medicaid policy; SelectHealth Community Care typically aligns with Utah Medicaid

Prior Authorization

Check payer-specific coverage / prior authorization

Always check payer-specific coverage rules and prior authorization requirements before scheduling or billing. Inclusion or exclusion of a code in a policy document does not guarantee member coverage or payment.

Verify plan-specific prior authorization rules and coverage exceptions
Inclusion/exclusion of codes in policy is informational only

Prior Authorization

Verify benefits and obtain authorization

Providers must verify member benefits and obtain any required prior authorization before delivering services. Contact Customer Service (member card) for benefit questions or Provider Relations for policy questions.

Verify benefits and eligibility prior to service date
Provider Relations: 801-442-3692; Members: phone on member ID

Prior Authorization

Preauthorization per member plan

Preauthorization requirements are determined per member plan. Even when a service is medically necessary, lack of an applicable benefit or missing authorization may lead to claim denial.

Obtain preauthorization per the member's benefit plan when required
Lack of authorization may result in denial even for medically necessary services

Denial Risk

Coverage denial risk for DYSIS

Because SelectHealth considers DYSIS investigational for Commercial/CHIP, claims for dynamic spectral imaging smart colposcopy are at risk of denial. Submiters should not expect authorization to override investigational/non-covered status.

Risk of denial for CPT 57465 under Commercial and CHIP plans
Authorization will not make investigational services payable

Denial Risk

Investigational procedure denial risk

Procedures or services coded with investigational CPT/HCPCS (e.g., CPT 0071T, 0072T; HCPCS C1886 for some ablation catheters) are considered investigational/unproven for listed indications and are at risk of denial.

Investigational codes noted: 0071T, 0072T, HCPCS C1886 (where indicated)
Use of investigational codes may trigger claim denial or coverage review

Denial Risk

Non-covered indications

SelectHealth does not cover procedures when the indication is not listed as medically necessary in the policy (e.g., hysterectomy for indications outside the policy criteria). Providers should confirm that the clinical indication meets policy criteria before submitting claims.

Hysterectomy not covered for indications outside those listed in the policy (considered not medically necessary)
Confirm indication aligns with policy prior to billing

Note

Coverage source and denial trigger

If CMS has an adopted determination, it governs Medicare coverage decisions. When CMS determinations are absent and InterQual is not used, SelectHealth Commercial policy may be applied. Inclusion/exclusion of a code in this document does not guarantee coverage.

CMS determinations take precedence for Medicare members
Absence of CMS/InterQual criteria may result in application of SelectHealth Commercial policy

Denial Risk

Risk of denial for elective early-term delivery

Elective (non-medically indicated) deliveries prior to 39 weeks are discouraged and may be denied; documentation showing a qualifying medical indication is required to support coverage for early delivery.

Risk of denial for elective early-term delivery (before 39 weeks) without a qualifying indication
Document the specific qualifying indication when requesting authorization

Billing Rule

Billing code guidance

When billing endometrial ablation or related procedures, use the covered CPT codes that correspond to the service performed (e.g., 58353, 58356, 58563). Do not use investigational codes (0071T, 0072T) for routine endometrial ablation billing.

Use covered CPT codes: 58353, 58356, 58563
Do not bill endometrial ablation services using investigational CPTs 0071T or 0072T

Note

Member benefits and provider contact

Providers should refer to the member's contract benefits to determine coverage and may contact Customer Service or Provider Relations with questions. Provider Relations is available at 801-442-3692.

Members: contact phone number on member ID card for benefits
Providers: SelectHealth Provider Relations 801-442-3692

Documentation Required

Required clinical documentation

Required clinical documentation varies by service but may include trial and duration of conservative therapies, imaging reports, biopsy/pathology, ultrasound measurements, and clinician notes describing symptoms and contraindications for alternative therapies.

Document trials of medical therapy (e.g., ≥12 weeks hormonal therapy for premenopausal AUB) and reasons for contraindication when applicable
Include ultrasound, biopsy, pathology, and symptom documentation as required by the specific policy

Documentation Required

Supporting documentation

When requesting authorization or appealing a denial, supply supporting clinical documentation: operative notes, imaging, pathology, medication trials and durations, and consultation notes (e.g., MFM consult for certain obstetric indications). Revision history and policy updates may affect required documentation.

Include operative reports, imaging, pathology, and medication trial documentation with authorization requests
Provide MFM or specialist consult notes when policy requires consultation

Documentation Required

Documentation of medical indication

When elective early delivery is proposed for a non-listed indication, document the medical rationale clearly; for 'other' indications, include documentation and consider MFM consultation and approval when required by policy.

Document the specific medical indication when it is not explicitly listed
Include MFM physician name/consultation when required

Billing Rule

Coverage determination & coding note

Codes listed in these policies are informational and may trigger coding review. Inclusion or exclusion of codes does not guarantee coverage — always verify benefits and obtain preauthorization when required. Contact Provider Relations or Customer Service for coverage questions.

Inclusion/exclusion of a code does not guarantee coverage or payment
Contact Provider Relations for coverage or coding questions

Note

Verify benefits and contact info

Before providing services, verify benefits and eligibility and obtain any required authorizations. For coverage or coding questions, contact SelectHealth Provider Relations at 801-442-3692 or Member Services via the number on the member's ID card.

Verify benefits and eligibility prior to service
Provider Relations: 801-442-3692; Members: number on member ID

Step Therapy

No step-therapy specified

No formal step-therapy sequence is specified in these policy excerpts. Clinical factors, patient preferences, and reimbursement may influence choice of technique, but providers should follow the documented conservative-therapy prerequisites where applicable.

No mandated step-therapy sequence specified
Follow conservative therapy prerequisites described in applicable policy sections

Step Therapy

Conservative therapy prerequisites

Where required by the specific policy (e.g., hysterectomy for AUB, pelvic pain, adenomyosis), providers must document trials of specified medical or less-invasive surgical therapies (such as hormonal therapy ≥12 weeks, LNG-IUS, endometrial ablation) unless contraindicated.

Examples of required conservative therapies: hormonal therapy ≥12 weeks, LNG-IUS, tranexamic acid, endometrial ablation
If therapies are contraindicated or not tolerated, document the reason

Documentation Required

Document prior conservative therapy when indicated

When conservative therapy is required by policy, document the type of therapy, duration (e.g., ≥12 weeks for hormonal therapy), response, and reasons it was contraindicated or not tolerated if applicable. Lack of documented conservative therapy when required may result in denial.

Document therapy type and duration (e.g., hormonal therapy ≥12 weeks)
If therapy not tried, document contraindication or intolerance

Step Therapy

No step therapy protocols specified in this section

No formal step-therapy protocols are specified in the extracted policy sections. Providers should apply clinical judgment and follow any conservative-therapy prerequisites described for the specific indication.

No step therapy protocols specified in these excerpts
Follow indication-specific conservative therapy requirements when present

Clinical considerationsThese techniques are generally quicker and may require less anesthesia but serious complications (e.g., uterine perforation) remain possible

Comparative evidenceLiterature offers mixed evidence comparing methods; patient factors and device characteristics often guide selection

inv-108: 58356 — Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed.

CPT 58356 descriptionEndometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed

Billing contextListed among covered CPT codes for endometrial ablation procedures under SelectHealth policy #329

Procedure classConsidered a form of endometrial ablation for heavy menstrual bleeding/dysfunctional uterine bleeding indications

inv-109: Endometrial ablation — Procedures that destroy or remove the endometrial lining using various energy sources or techniques.

DefinitionEndometrial ablation: procedures that destroy or remove the endometrial lining using various energy sources or techniques to reduce menstrual bleeding

IndicationsUsed for menorrhagia/dysfunctional uterine bleeding when conservative therapies have failed or are contraindicated

Technique variabilityMultiple global and hysteroscopic techniques exist; no single method identified as superior across all outcomes

inv-110: Devices referenced — Examples include NovaSure, ThermaChoice, Her Option uterine cryoblation, HydroThermAblator, and Cavaterm systems.

Examples of devicesExamples include NovaSure, ThermaChoice, Her Option uterine cryoblation, HydroThermAblator, and Cavaterm systems

Regulatory referencesMultiple FDA summaries of safety and effectiveness are cited for these devices in the policy literature

Clinical noteDevice choice may be influenced by uterine anatomy, patient preference, fertility desires, and contraindications

inv-111: Hysterectomy definition — Surgical removal of the uterus; partial removes uterus only, total removes uterus and cervix; may include salpingo-oophorectomy.

DefinitionHysterectomy: surgical removal of the uterus; partial (subtotal) removes uterus only, total removes uterus and cervix; may include salpingo-oophorectomy (removal of fallopian tubes and/or ovaries)

ApproachesCan be performed abdominally, vaginally, or via laparoscopic/robotic approaches

Associated proceduresMay be combined with oophorectomy or salpingectomy depending on indication and risk factors

inv-112: Oophorectomy — Surgical removal of one or both ovaries; can be unilateral or bilateral for treatment or prevention of disease.

DefinitionOophorectomy: surgical removal of one or both ovaries; may be unilateral or bilateral for treatment or risk-reduction

Coverage contextSelectHealth covers oophorectomy with hysterectomy when specified criteria (including age and high-risk genetic or clinical factors) are met

IndicationsPerformed for ovarian pathology, cancer risk reduction, endometriosis, infertilty-related indications, or as listed in policy

inv-113: Preferred surgical approach — Vaginal hysterectomy is preferred when feasible; laparoscopic preferred over abdominal when not feasible.

Preferred surgical approachVaginal hysterectomy is preferred when feasible; when not feasible, laparoscopic hysterectomy is preferred over abdominal approach

Evidence baseCochrane reviews support vaginal approach for faster recovery and fewer complications compared to abdominal hysterectomy

Patient counselingSurgical approach selection should consider patient anatomy, surgeon expertise, and clinical indications

inv-114: Morcellation contraindication — FDA recommends power morcellators be contraindicated when tissue is known or suspected to contain malignancy or in peri/postmenopausal patients.

Morcellation contraindicationFDA recommends power morcellators be contraindicated when tissue to be morcellated is known or suspected to contain malignancy or in peri/postmenopausal patients

Patient counselingInform patients about potential risk of spreading unsuspected cancer with power morcellation and consider alternatives

Policy implicationUse of power morcellators in these contexts is contraindicated and may affect coverage or appropriateness of procedure

inv-115: Laparoscopic RFA — Laparoscopic radiofrequency ablation (RFA): laparoscopic delivery of radiofrequency energy with intraoperative ultrasound guidance to ablate fibroids.

Laparoscopic RFA definitionLaparoscopic radiofrequency ablation (RFA): laparoscopic delivery of radiofrequency energy with intraoperative ultrasound guidance to ablate uterine fibroids

Indication limitsCovered for symptomatic fibroids in patients desiring uterine preservation when criteria (including fibroid size <10 cm) are met

CounselingLimited data on reproductive outcomes; counsel patients desiring fertility accordingly

inv-116: Chronic pelvic pain (CPP) — pain below the navel lasting at least 6 months, severe enough to cause functional disability or require treatment.

Chronic pelvic pain (CPP)Pain below the navel lasting at least 6 months, severe enough to cause functional disability or require treatment

Relation to hysterectomyCPP is a common indication considered for hysterectomy when conservative measures fail and other causes are excluded

Treatment considerationsNerve transection procedures (LUNA/PSN) have limited evidence and are not covered per policy

inv-117: LUNA / PSN — LUNA: laparoscopic uterine nerve ablation; PSN: presacral neurectomy.

LUNA / PSN definitionsLUNA: laparoscopic uterine nerve ablation (destruction of uterine nerve fibers via uterosacral ligament); PSN: presacral neurectomy (interruption of sympathetic innervation at superior hypogastric plexus)

Coverage stanceSelectHealth does NOT cover LUNA or PSN; considered experimental/investigational

Evidence noteSystematic reviews and RCTs do not support effectiveness for chronic pelvic pain in general use

inv-118: Elective induction — Induction of labor when there is no clear medical benefit compared with continuation of pregnancy.

Elective induction definitionInduction of labor when there is no clear medical benefit to mother or child compared with continuation of pregnancy

Term classificationsEarly-term: 37 0/7–38 6/7 weeks; Full-term: 39 0/7–40 6/7 weeks; Late-term: 41 0/7–41 6/7 weeks; Post-term: ≥42 0/7 weeks

Policy principleNon-medically indicated elective delivery prior to 39 weeks is discouraged due to neonatal morbidity

inv-119: Term classifications — Early-term: 37w0d–38w6d; Full-term: 39w0d–40w6d; Late-term: 41w0d–41w6d; Post-term: ≥42w0d.

Term classifications (detailed)Early-term: 37w0d–38w6d; Full-term: 39w0d–40w6d; Late-term: 41w0d–41w6d; Post-term: ≥42w0d

Clinical relevanceDefinitions used to guide timing of delivery and coverage determinations for elective induction

Provider guidanceAccurate determination of gestational age is required when considering early or elective induction

inv-120: Early-term — Deliveries occurring at 37 0/7–38 6/7 weeks' gestation.

Early-term definitionDeliveries occurring at 37 0/7–38 6/7 weeks' gestation

Coverage implicationElective early-term delivery without documented medical indication is considered not medically necessary

Clinical guidanceACOG and SMFM advise against nonindicated delivery prior to 39 weeks due to neonatal risk

inv-121: Late-preterm — Deliveries occurring at 34 0/7–36 6/7 weeks' gestation.

Late-preterm definitionDeliveries occurring at 34 0/7–36 6/7 weeks' gestation

Clinical riskLate-preterm and early-term births have higher neonatal morbidity compared with full-term births

Policy noteCertain maternal or fetal conditions may justify late-preterm or early-term delivery when documented

inv-122: OVA1 / OvaCalc — A multivariable regression-based MIA combining five serum biomarkers.

OVA1 / OvaCalc descriptionOVA1 (OvaCalc) is a multivariable regression–based multivariate index assay combining five serum biomarkers into a numeric risk index (0.0–10.0)

CutoffsCutoff values: 5.0 for premenopausal; 4.4 for postmenopausal (per OvaCalc training data)

Intended useDesigned to estimate ovarian malignancy risk for adnexal masses prior to planned surgery

inv-123: OVERA (MIA2G) and ROMA — Other multibiomarker algorithms: OVERA/MIA2G uses CA-125, transferrin, apolipoprotein A1, FSH, and HE4; ROMA combines CA-125 and HE4 with menopausal status.

OVERA (MIA2G) and ROMAOther multibiomarker algorithms: OVERA/MIA2G uses CA-125, transferrin, apolipoprotein A1, FSH, and HE4; ROMA combines CA-125 and HE4 with menopausal status

Policy noteSelectHealth lists OVERA/MIA2G and ROMA among biomarker algorithms discussed in the literature; policy excludes these tests for certain commercial indications

Clinical useThese algorithms estimate malignancy risk for adnexal masses but SelectHealth considers them investigational/not covered for the stated indication

inv-124: Hereditary ovarian cancer syndrome — Includes breast-ovarian cancer syndrome, site-specific ovarian cancer syndrome, and Lynch syndrome.

Hereditary ovarian cancer syndromeIncludes breast-ovarian cancer syndrome, site-specific ovarian cancer syndrome, and Lynch syndrome; associated with increased lifetime ovarian cancer risk

Clinical implicationWomen with hereditary syndromes may be candidates for prophylactic oophorectomy after counseling and completion of childbearing

EvaluationFamily pedigree and genetic testing recommended to assess syndrome presence and guide management

inv-125: SEE-FIM protocol — Sectioning and Extensively Examining the FIMbriated end — pathologic protocol involving longitudinal sectioning of the fimbria.

SEE-FIM protocolSectioning and Extensively Examining the FIMbriated end (SEE-FIM): longitudinal sectioning of the fimbria with extensive cross-sectioning of the remaining tube at 2-mm intervals to detect occult lesions

Surgical-pathology relevanceRecommended as part of ideal pathologic examination during risk-reducing salpingo-oophorectomy to optimize detection of occult carcinoma

Associated recommendationCombine SEE-FIM with standardized 5-step surgical management for RRSO to improve occult cancer detection

inv-126: RRSO — Risk-reducing salpingo-oophorectomy (RRSO).

RRSO definitionRisk-reducing salpingo-oophorectomy (RRSO): prophylactic removal of fallopian tubes and ovaries to reduce ovarian/tubal/peritoneal cancer risk in high-risk women

Candidate criteriaConsidered for premenopausal high-risk women (e.g., BRCA mutation carriers) typically age ≥35 years; counseling required

Recommended protocolsPerform standardized 5-step surgical management and SEE-FIM pathologic review when feasible

For the Commercial plan policy, added the OVERA (MIA2G) and ROMA tests to the list of excluded (investigational) tests.