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Laparoscopic Excision of Tubes and Ovaries Hs-263

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Laparoscopic Excision of Tubes and Ovaries Hs-263 LAPAROSCOPIC EXCISION OF TUBES AND OVARIES HS-263 Easy Choice Health Plan, Inc. Harmony Health Plan of Illinois, Inc. Missouri Care, Inc. ‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Plans of New Jersey, Inc. WellCare Health Insurance of Arizona, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc. WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc. Laparoscopic Excision WellCare of South Carolina, Inc. of Tubes and Ovaries WellCare of Texas, Inc. Policy Number: HS-263 WellCare Prescription Insurance, Inc. Original Effective Date: 8/7/2014 Windsor Health Plan Windsor Rx Medicare Prescription Drug Plan Revised Date(s): 7/11/2015 APPLICATION STATEMENT The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Clinical Coverage Guideline page 1 Original Effective Date: 8/7/2014 - Revised: 7/11/2015 LAPAROSCOPIC EXCISION OF TUBES AND OVARIES HS-263 DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult www.wellcare.com/Providers/CCGs for list of current LOBs. BACKGROUND Most ovarian cysts develop as consequence of disordered ovulation in which the follicle fails to release the oocyte. The follicular cells continue to secrete fluid and expand the follicle, which over time can become cystic. Ovarian cysts are quite common and involve all age groups, occurring in both symptomatic and nonsymptomatic females. Six percent of 5000 healthy women in a study reported by Campbell et al had detectable adnexal masses on transabdominal ultrasound. Of these, 90% were cystic with most diagnosed as simple cysts.1 The ovaries are the female pelvic reproductive organs that house the ova and are also responsible for the production of sex hormones. They are paired organs located on either side of the uterus within the broad ligament below the uterine (fallopian) tubes. The ovary is within the ovarian fossa, a space that is bound by the external iliac vessels, obliterated umbilical artery, and the ureter. The ovaries are responsible for housing and releasing ova, or eggs, necessary for reproduction.1,3 Salpingo-oophorectomy is the removal of the fallopian tube (salpingectomy) and ovary (oophorectomy). A unilateral salpingo-oophorectomy is appropriate for patients in whom an ovary is unable to be preserved, including cases of ruptured ectopic pregnancy with an inability to achieve hemostasis without removal of the tube and ovary, adnexal torsion in which the ovary and tube are necrotic, a tuboovarian abscess not responsive to antibiotics, or a benign ovarian mass in which there is no remaining normal ovarian tissue able to be conserved. A bilateral salpingo-oophorectomy is generally one of three types: elective at time of hysterectomy for benign conditions, prophylactic in women with increased risk of ovarian cancer, or because of malignancy.2,3 An ovarian cystectomy is the excision or aspiration of a cyst in the ovary that is considered benign in nature. It could either be a simple cyst (liquid in nature) or a complex cyst (one with solid component in addition to the liquid cyst). POSITION STATEMENT Applicable To: Medicaid Medicare 1. Laparoscopic excision of fallopian tubes (salpingectomy) is considered medically necessary when the following criteria are met: a) Member has experienced an ectopic pregnancy; OR, b) Member has an infection or sexually transmitted disease (e.g., gonorrhea, syphilis, chlamydia) also known as hydrosalpinx; OR, c) Member has experienced complications as a result of childbirth, abortion or insertion of intrauterine devices (IUDs). 2. Laparoscopic excision of ovaries (ovarian cystectomy or oophorectomy) is considered medically necessary when the following criteria are met: a) Ovarian cyst* is confirmed by special imaging; AND, b) Member is having symptoms related to the ovarian cyst such as pelvic pain; AND, c) Failed conservative attempt to dissolve the cyst with hormone treatment such as oral contraceptives must be documented unless hormone use is contraindicated (e.g., member is a smoker, has a history of breast or ovarian cancer, and/or an allergic reaction). * Cysts include those that can be managed by cystectomy (e.g., dermoid, serous or mucinous cystadenoma, symptomatic hemorrhagic ovarian cyst, ovarian torsion, endometrioma, persistent simple cyst) Clinical Coverage Guideline page 2 Original Effective Date: 8/7/2014 - Revised: 7/11/2015 LAPAROSCOPIC EXCISION OF TUBES AND OVARIES HS-263 NOTE: Diagnosis of endometriosis is not required for this procedure if the member meets the above criteria. A contraindication for this procedure is concern for malignancy (ascites, abnormal CA125, ultrasound suggestive of malignancy). CODING Covered CPT®* Codes 58661 Laparoscopy, with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) 58662 Laparoscopy, surgical, removal of lesions/cysts of ovaries and pelvis 59151 Laparoscopic Treatment of Ectopic, w/ Salpingectomy and/or Oophorectomy HCPCS Codes – No applicable codes. Covered ICD-9-CM Procedure Codes 65.41 Oophorectomy (unilateral) with salpingectomy laparoscopic 65.63 Oophorectomy (bilateral) with salpingectomy laparoscopic 65.25 Cystectomy(excision of lesion) ovary that by laparoscope Covered Covered ICD-9-CM Diagnosis Codes 620.2 Ovarian cyst (twisted) 617.1 Chocolate cyst 620.1 Luteum 220 Dermoid 620.0 Follicular(hemorrhagic) 654.4 In pregnancy or childbirth 614.1 Hydrosalpinx Covered DRAFT ICD-10-CM Codes D27.0 Benign neoplasm of right ovary D27.1 Benign neoplasm of left ovary D27.9 Benign neoplasm of unspecified ovary N70.12 Chronic oophoritis N70.13 Chronic salpingitis and oophoritis N80.1 Endometriosis of ovary N83.0 Follicular cyst of ovary N83.1 Corpus luteum cyst N83.20 Unspecified ovarian cysts N83.29 Other ovarian cysts N86 Erosion and ectropion of cervix uteri O34.529 Maternal care for prolapse of gravid uterus, unspecified trimester O34.599 Maternal care for other abnormalities of gravid uterus, unspecified trimester O34.521 Maternal care for prolapse of gravid uterus, first trimester O34.522 Maternal care for prolapse of gravid uterus, second trimester O34.523 Maternal care for prolapse of gravid uterus, third trimester O34.591 Maternal care for other abnormalities of gravid uterus, first trimester O34.592 Maternal care for other abnormalities of gravid uterus, second trimester O34.593 Maternal care for other abnormalities of gravid uterus, third trimester O34.591 Maternal care for other abnormalities of gravid uterus, first trimester O34.592 Maternal care for other abnormalities of gravid uterus, second trimester O34.593 Maternal care for other abnormalities of gravid uterus, third trimester O34.521 Maternal care for prolapse of gravid uterus, first trimester Clinical Coverage Guideline page 3 Original Effective Date: 8/7/2014 - Revised: 7/11/2015 LAPAROSCOPIC EXCISION OF TUBES AND OVARIES HS-263 O34.522 Maternal care for prolapse of gravid uterus, second trimester O34.523 Maternal care for prolapse of gravid uterus, third trimester O34.591 Maternal care for other abnormalities of gravid uterus, first trimester O34.592 Maternal care for other abnormalities of gravid uterus, second trimester O34.593 Maternal care for other abnormalities of gravid uterus, third trimester O34.591 Maternal care for other abnormalities of gravid uterus, first trimester O34.592 Maternal care for other abnormalities of gravid uterus, second trimester O34.593 Maternal care for other abnormalities of gravid uterus, third trimester *Current Procedural Terminology (CPT®) 2015 American Medical Association: Chicago, IL. REFERENCES 1. Amesse, L.S. Ovarian cystectomy. http://emedicine.medscape.com/article/1848505-overview. Published 2012. Accessed June 30, 2015. 2. Ward, S.M. Salpingo-oophorectomy. http://emedicine.medscape.com/article/1894587-overview. Published (2012).Accessed June 30, 2015. 3. American Congress of Obstetricians and Gynecologists. (2007). Clinical bulletin no. 83: management of adnexal masses. Obstetrics and Gynecology, 110, 201–214. MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Action 7/11/2015 Approved by MPC. No changes. 8/7/2014 Approved by MPC. New. Clinical Coverage Guideline page 4 Original Effective Date: 8/7/2014 - Revised: 7/11/2015 .
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