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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyViva Health IUD Prior Auth Coverage | OpenPayer
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    CurrentViva Health PlanPolicy s-032

    Intrauterine Device (IUD) for Endometrial Hyperplasia

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    This policy governs medical necessity, authorization, documentation, and billing for a progestin-containing IUD used to manage endometrial hyperplasia for VIVA Medicare members.

    Policy Summary
    PayerViva Health Plan
    PolicyIntrauterine Device (IUD) for Endometrial Hyperplasia
    Policy CodePolicy s-032
    Change TypeNo material change
    Effective DateN/A
    Last ReviewSep 15, 2026
    Next Review DateN/A
    Key ActionSubmit requests billed with CPT 58999 as a surgical authorization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Dual diagnosisDiagnosis coding requirement
    >4 mmRequired ultrasound finding
    CPT 58300Auto-denied insertion code
    CPT 58999Billing code

    Medical Necessity and Coverage Criteria

    Policy Summary
    PayerViva Health Plan
    PolicyIntrauterine Device (IUD) for Endometrial Hyperplasia
    Policy CodePolicy s-032
    Change TypeNo material change
    Effective DateN/A
    Last ReviewSep 15, 2026
    Next Review DateN/A
    Key ActionSubmit requests billed with CPT 58999 as a surgical authorization.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaBilling and Diagnosis CodingAuthorization, Documentation, and Billing ActionsClinical Background

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Medical necessity and coverage criteria

    The progestin-containing IUD may be approved when the service is reasonable and necessary, the required diagnosis and clinical documentation are present, and the applicable pathology-specific criteria are met.

    Core medical-necessity requirements

    • Clinical documentation

      • Required record elements

        • The medical record documents post-menopausal bleeding.
        • The medical record documents evaluation of abnormal uterine bleeding.
        • A transvaginal ultrasound is on file with a documented endometrial stripe greater than 4 mm.>4 mm
        • A pathology biopsy report is on file.

      • Appropriate clinical circumstance

        • The patient is not a reasonable surgical candidate.
        • The patient wishes to preserve fertility.

      • Reasonable and necessary treatment

        • Use of the progestin-containing IUD is reasonable and necessary for the diagnosis or treatment of illness or to improve the patient's clinical condition.
        • The treatment meets applicable Medicare statutory and regulatory requirements and the standard of medical practice regarding IUD effectiveness for the diagnosis and condition.

      • Pathology-specific treatment pathway

        • Simple or benign endometrial hyperplasia

          • The pathology supports simple or benign endometrial hyperplasia.
          • A progesterone IUD is a reasonable treatment option.
          • A copper IUD is not proposed as the treatment option.

            A copper IUD is not a reasonable treatment option for simple or benign endometrial hyperplasia.

        • EIN or complex endometrial hyperplasia

          • The pathology supports EIN or complex endometrial hyperplasia.
          • Documentation supports that the patient is a poor surgical candidate.

    • Required diagnosis combination

      • Group 1: Abnormal uterine and vaginal bleeding, unspecified is documented.One diagnosis required
      • Group 2: One of the following is documented: N85.00, endometrial hyperplasia, unspecified; or N85.01, benign endometrial hyperplasia.One diagnosis required

    A copper IUD is not a reasonable treatment option for simple or benign endometrial hyperplasia.

    CPT 58300 (insertion of an IUD or contraceptive device) is not payable under Medicare and will be automatically denied.

    Billing and Diagnosis Coding

    Medicare nonpayable / auto-denied IUD insertion codeCPTNot Covered
    58300Insertion of device (IUD) or contraceptive devices or medication
    Billing and authorization codeCPT
    58999Unlisted procedure, female genital system (nonobstetrical)
    Group 1: Required abnormal bleeding diagnosisICD-10Covered
    Abnormal uterine and vaginal bleeding, unspecified
    Group 2: Endometrial hyperplasia diagnosis; one required with Group 1ICD-10Covered
    N85.00Endometrial hyperplasia, unspecified
    N85.01Benign endometrial hyperplasia
    Transvaginal ultrasound
    Required endometrial stripe measurementGreater than 4 mm

    Authorization, Documentation, and Billing Actions

    Prior Authorization

    Submit as a surgical authorization

    Because the IUD is billed with CPT 58999, Health Services will process the request as a surgical authorization.

    Documentation Required

    Include required clinical documentation

    The medical record must clearly document the specific clinical circumstances supporting medical necessity for the service.

    • Post-menopausal bleeding
    • Evaluation of abnormal uterine bleeding
    • Transvaginal ultrasound with a documented endometrial stripe greater than 4 mm
    • Pathology biopsy report
    Documentation Required

    Document eligibility for EIN or complex hyperplasia

    For EIN or complex endometrial hyperplasia, document that the patient is a poor surgical candidate and that current nonsurgical management options are limited to hormonal therapy.

    Denial Risk

    Avoid CPT 58300 for IUD insertion

    Do not bill CPT 58300 for IUD insertion. Medicare does not allow payment for this code, and it will be automatically denied.

    Denial Risk

    Prevent medical-necessity denial

    Requests may fail medical-necessity review when the record does not document the required clinical circumstances, when a copper IUD is proposed for simple or benign hyperplasia, or when EIN or complex endometrial hyperplasia lacks documentation of poor surgical candidacy and limited nonsurgical management options.

    Clinical Background

    A progestin-containing, hormone-eluting IUD may be used as an alternative treatment for endometrial hyperplasia in patients who are not reasonable surgical candidates or who wish to preserve fertility. For simple or benign hyperplasia, a progesterone IUD is considered a reasonable treatment option. For EIN or complex endometrial hyperplasia, documentation must support that the patient is a poor surgical candidate and that current nonsurgical management options are limited to hormonal therapy.

  1. Current nonsurgical management options are limited to hormonal therapy.