CPT 58720, in plain terms, covers Surgical removal of one or both ovaries and fallopian tubes through an abdominal incision. CPT 58720 is referenced in 8 tracked payer policy changes from Sentara Health Plans, Premera Blue Cross, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 58720 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 58720 on AAPC
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Premera's November 2024 medical policy and coding update changes medical necessity criteria for several drugs and services, including Dupixent, Xolair, trastuzumab and rituximab products, and GnRH analogs. It also adds coding updates that require review for medical necessity and prior authorization, including knee arthroplasty codes 27440, 27442, 27443 and 27445, amyloid antibody code J0175, and codes for biofeedback, endometrial ablation, home apnea monitoring and posterior tibial nerve stimulators.
Premera's December 2024 medical policy and coding update adds medical necessity criteria for lymphedema and lipedema surgery, a new shoulder arthroplasty policy, and new or revised criteria for drugs including Ocrevus Zunovo, Dupixent, Ebglyss, Leqselvi and Wegovy. It also lists coding updates that require review for medical necessity and prior authorization, including cervical spine surgery codes 63001, 63015, 63040, 63050, 63051, 63075, 63081 and 63265, and it places infusion drugs such as Tyruko and Alyglo under site-of-service review.
Policy 7.01.84 sets the criteria for gender affirming surgery and treatments for commercial and Medicare Advantage members, with a current effective date of May 21, 2026. Gender affirming surgery may be considered medically necessary when the member has reached age 18 (except for mastectomy), one letter from a qualified professional documents gender dysphoria that is marked and sustained for at least 6 months, and the other general criteria are met. Breast augmentation, hysterectomy, gonadectomy and genital reconstructive surgery each require six months of continuous hormone therapy or a documented contraindication to hormone therapy, and voice modification and voice therapy require review by a Health Plan Behavioral Health Medical Director.
Aetna considers prophylactic mastectomy medically necessary for reduction of breast cancer risk in listed high-risk women, including women diagnosed with breast cancer at 45 years of age or younger, women with a BRCA1 or BRCA2 mutation confirmed by molecular susceptibility testing, and women who received radiation treatment to the chest between ages 10 and 30. Prophylactic bilateral oophorectomy or salpingo-oophorectomy is medically necessary for selected women with listed risk factors who meet specific family history or germline mutation criteria, and germline multigene panel testing is medically necessary once per lifetime for persons who meet one or more NCCN testing criteria for high-penetrance breast cancer susceptibility genes. Testing for BARD1, MUTYH, NBN, and other genes or indications not listed in the policy is not covered.
Effective January 1, 2020, for individual plans only, subcutaneous implantable cardiac defibrillator code 33270, total ankle replacement codes 27702 and 27703, negative pressure wound therapy codes A6550, A7000 and E2402, and spinal orthosis codes such as L0450 and L0460 now require review for medical necessity and prior authorization, along with nerve block codes such as 64450 and 64490 and trigger point injection codes 20552 and 20553. Effective January 1, 2020, for individual plans only, many other codes including 92132, 77046 through 77049, 90460, 90461 and E0424 now require review for medical necessity. Effective September 1, 2019, hyoid myotomy code 21685 and denosumab code J0897 now require review for medical necessity and prior authorization, while lumbar discectomy codes 62287 and 62380 are reviewed for investigational status and no longer require prior authorization.
Effective January 3, 2025, Premera HMO medical necessity criteria for Dupixent (dupilumab) in moderate to severe asthma were updated, requiring two or more asthma exacerbations in the previous 12 months requiring oral corticosteroids, or one or more exacerbations requiring hospitalization, an emergency department visit, or an urgent care visit, or forced expiratory volume in 1 second of less than 80% predicted, with a blood eosinophil count greater than 300 cells/mcL. The same effective date added Humira (adalimumab) criteria for psoriatic arthritis, Crohn's disease, ulcerative colitis, uveitis, sarcoidosis and pyoderma gangrenosum, moved Inflectra (infliximab-dyyb) to a first-line TNF-alpha antagonist option for several indications, and removed Hyrimoz (adalimumab-adaz) from first-line options. A new Shoulder Arthroplasty policy (7.01.590) with medical necessity criteria for total, reverse, hemi, and revision shoulder arthroplasty is also listed under the January 3, 2025 effective date, and Restasis (cyclosporine ophthalmic emulsion) was added for dry eye disease in individuals aged 18 years and older effective October 1, 2024.
Effective January 22, 2026, gender reassignment surgery is considered medically appropriate for members age 18 or older who have referral letters from two qualified NYS licensed health professionals, and the policy lists the covered surgeries and services for Medicaid Managed Care Plan and Health and Recovery Plan members. The January 22, 2026 annual review moved the hormone therapy criteria to Pharmacy policies with policy intent unchanged, and a March 20, 2026 policy edit revised policy statement references for alignment, also with intent unchanged.
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