Is Endometriosis Covered By Insurance?

Connecting with a high volume excision surgeon who was truly trained in the accurate detection of endometriosis was like a dream come true for me as an endometriosis patient who had gone 31 years without a diagnosis. This doctor was aware of all of my symptoms, acknowledged and validated my experience, knew how to do the only type of surgery capable of removing the lesions – and, most importantly, bolstered my confidence in myself and my symptoms. The sensation of having a doctor sit across from you, look you in the eyes, and tell you that he feels you have endometriosis is nearly as soothing as the procedure itself.

I scheduled my operation soon after, despite having no idea how I was going to pay for it. I ended up filing a claim with my insurer, who covered the entire cost, and now I teach women how to do what I did as part of my advocacy work. Here are some of the things I discovered along the road.

Endometriosis patients are stuck in a “care gap” or “access to care gap,” as it’s known in the medical sector. This means that most insurance do not cover the surgeon’s labor fees for excision surgery. The factors that contribute to this “care gap” are numerous.

  • Endometriosis removal via fulguration, ablation, coagulation, and excision were all lumped together in a 1992 Medicare Part B judgement.
  • Medicare tables are used by all insurers to determine how much they will reimburse. Because of the aforementioned, there is no code for excision surgery in these tables.
  • The American Medical Association does not designate excision as a specialty (AMA). There are no standard certifications or boards.
  • Even if hundreds of clinical, peer-reviewed articles state otherwise, the American Congress of Obstetricians and Gynecologists (ACOG) does not acknowledge excision as a speciality or as the gold standard of surgical therapy for endometriosis.
  • Excision and diagnosis of endometriosis are not taught in medical schools since doctors can’t earn a career practicing it unless they work at a prominent university.
  • Doctors are protected under the “standard of care.” This medical word basically indicates that if the type of treatment you’re giving your patients is similar to what your peers are giving, you’re safe from liability. Even when hormonal medications, such as the pill, have been found to be palliative at best and harmful at worst for many women, as in the instance of endometriosis.

I’m describing these methods because endometriosis sufferers must understand that they’re dealing with major structural concerns over which they have no control. This is crucial to remember when filing your appeal for your own sanity.

As we all know, all of the foregoing is a nightmare for patients. Because surgeons are not compensated by insurance companies, they must either work at a university or accept direct payment from patients. Patients don’t always have access to a university-based surgeon. Meanwhile, as an endo patient, getting trapped in this “care gap” means your symptoms will increase while you try to find out how to pay for the surgery.

So, what to do?

The most important thing to remember when approaching your insurance is that their business model is built on the assumption that patients will give up. The key is to never give up!

You must mount your case six to eight weeks prior to surgery (even though many women have appealed post-surgery and gotten reimbursed for some or all of their expenses). Pre-surgical appeals provide you the opportunity for a peer-to-peer review with your surgeon and insurance, which can be critical in getting your operation covered.

Next, you’ll want to make sure that if your insurer agrees to pay your surgeon in-network prices, your surgeon is willing to take them. In most situations, in-network fees will be pennies on the dollar due to coding issues and non-recognition of the speciality. So, if your insurer says “yes, we’ll pay in-network,” you should confirm with them exactly how much they’ll pay before surgery, and run that information by your surgeon to be sure they’ll accept those rates. If they are, obtain written confirmation from your insurer prior to surgery.

In the best-case situation, you should request a Single Case Rate. This is where your surgeon and insurer talk over the phone to work out a reasonable price for this extremely difficult surgery. With a Letter of Agreement, you certify that this rate has been accepted, and this is your contract requiring the insurer to pay the surgeon. This is the best case situation since surgeons are compensated fairly and you, the patient, are not responsible for the medically essential care you require. You may be charged a deductible or co-insurance, but it will be on an in-network basis, which is usually far less expensive. A Single Case Rate appeal follows the same criteria as a Medicare or Tricare appeal. The procedure and who you contact may differ, but the clinical evidence you provide and the manner in which you provide it are the same.

The importance of persistence and follow-up cannot be overstated. Contact your insurance, request a Single Case Rate, enlist the help of your surgeon’s office, have clinical data concerning excision on hand (letters from your surgeon, primary care physician, etc.) and be ready to support your case. Then phone, email, and harass them! You have the ability to succeed.

How much does it cost to have endometriosis surgery?

The cost of a surgical operation varies, ranging from $14,564.73 for a vaginal hysterectomy to $26,002 for a total hysterectomy (other peritoneal adhesiolysis). $21,268.26 for laparoscopy. Microlaparoscopy under sedation costs $202.99, microlaparoscopy under general anesthesia costs $350.46, and microlaparoscopy under general anesthesia costs $388.57. (conventional laparoscopy).

Is endometriosis laparoscopy covered by insurance?

  • Laparoscopy can cost anywhere from $1,700 to $5,000, depending on the doctor and if the procedure is performed to diagnose or treat a problem. Endometriosis, ovarian cysts, scar tissue, and blocked or damaged fallopian tubes can all be treated via laparoscopy.
  • Laparoscopy is generally covered by health insurance because it is a diagnostic test that is also used to treat health conditions, such as endometriosis, that might have an impact on a patient’s overall health. It is, however, critical to double-check with the insurance.
  • Insurance coverage for infertility treatment is required in some states, with some exceptions. States that require coverage are listed by the American Society for Reproductive Medicine.
  • Out-of-pocket costs for individuals with insurance can go into the hundreds of dollars or even thousands of dollars, depending on whether they have copays for doctor visits or a portion of the treatment reimbursed; some plans only cover 50 to 80 percent.
  • To inspect the uterus, fallopian tubes, and ovaries, the doctor makes a small incision in the abdomen and inserts a telescope-like instrument. If scar tissue or other problems are discovered during the diagnostic procedure, they can easily be rectified by connecting surgical instruments to the scope.
  • An summary of laparoscopic surgery can be found at the Advanced Fertility Center of Chicago.
  • Patients who pay for reproductive tests and treatment out of pocket may be eligible for monetary discounts at some clinics.
  • The doctor you choose should be an American College of Obstetricians and Gynecologists board-certified obstetrician and gynecologist with training and expertise conducting laparoscopy.

Is a hysterectomy covered by insurance with endometriosis?

Insurance companies, on the other hand, have been known to reject coverage to endometriosis patients who desire a hysterectomy, claiming that it is an elective treatment.

Is it worth getting endometriosis surgery?

Surgery, like hormone therapy, resolves endometriosis discomfort in the majority of women. However, it does not ensure long-term results. According to some studies, the majority of women—roughly 60 to 80 out of 100—experience pain reduction in the first few months after surgery.

How is endometriosis removed?

Endometriosis can be treated as soon as it is discovered. Laparoscopy is a surgical procedure used to diagnose endometriosis. Endometrial lesions (endometrial tissue implants outside the endometrium) can be cut away (excised) or burned away with a high-energy heat source like a laser (ablated). Advanced illness involving extensive sections of the rectum or bigger lesions makes laparoscopic treatment more difficult.

How are endometriomas treated?

Simple puncture: The fluid from the cyst is drained at the end of the surgery. More than half of individuals with endometriomas who were treated with simple puncture had them return. A more severe surgical technique, such as removing the lump, can result in substantial adhesions (scar tissue) that inhibit the ovary from releasing an egg. As a result, experience is essential to avoid harm.

Draining the cyst and removing the cyst’s base with laser or electrosurgery is another option. Heat, on the other hand, can harm the ovary.

Cutting the cyst wall away is the preferred technique for reducing disease recurrence. This operation can potentially harm the ovary’s outer layer, which stores the eggs.

Drainage, medication, and surgery: Endometriomas can be drained, treated with medicine, and then surgically removed.

Pregnancy rates of 50% over three years have been observed in various different prospective studies. There are no randomized clinical trials that compare the various therapy options.

How is advanced endometriosis treated?

The care of severe endometriosis within the pelvic cavity, rectum, and vagina is the most difficult operation by laparoscopy or laparotomy (conventional abdominal surgery, which requires a wider incision). Several studies have found that 50 percent to 60 percent of cases treated with surgery result in pregnancy after two years. Endometriosis may return in 20% of instances, according to various studies.

How do I know if I have endometriosis?

The following tests can be used to look for physical signs of endometriosis:

  • Examining the pelvis. A pelvic exam involves your doctor manually palpating areas of your pelvis for abnormalities such as cysts on your reproductive organs or scars behind your uterus.

How long is recovery from endometriosis surgery?

What to expect after endometriosis surgery and how long it takes to recover Quick recovery within 3-4 days. Within 7-10 days, you should be able to exercise and have sexual relations, and you should be off work for one week. By 4-8 weeks, you should be fully recovered. Fertility returns within 4-8 weeks post surgery.

What does endometriosis look like?

A 30-year-old lady has been trying unsuccessfully to conceive for three years and suffers from painful menstruation cycles and sexual intercourse. Her doctor notices some discomfort at the top of her vagina during her pelvic exam and recommends further testing. A vaginal ultrasound reveals a 5 centimeter cyst on one of her ovaries. Other infertility tests, such as a hysterosalpingogram (an X-ray dye test to check her tubes) and her husband’s semen analysis, are both normal. Her doctor suspects she has endometriosis and recommends a laparoscopy, a minimally invasive procedure. She is discovered to have moderate (stage III) endometriosis during surgery. A laparoscope is used to remove an ovarian cyst and multiple endometrial implants. Soon after surgery, she was able to resume full exercise. Her pain subsides, and she becomes pregnant without further therapy two months later. Her pregnancy is uneventful, and she gives birth to a healthy child via vaginal delivery.

Endometriosis, despite being a prevalent female illness, can be a mystery to both women and healthcare providers.

This aberrant endometrium can develop on or into other organs, triggering an inflammatory reaction that causes discomfort and the creation of scar tissue. Endometriosis is most commonly found on the peritoneum, which is the lining of the abdomen and pelvic, near the uterus. Endometriosis usually grows on the peritoneum’s surface, but it can also penetrate deep into the lining. It can grow on the surface of the ovaries, but it can also spread deeper into the ovarian tissue, causing endometriomas. Endometriosis can spread to other organs, such as the intestines, bladder, vaginal canal, and ureters, which connect the kidney to the bladder. Endometriosis can be present outside the pelvic cavity in practically any part of the body, despite its rarity.

On a cyclic basis, women may have rectal bleeding or localized pain and edema.

Endometriosis is also linked to infertility, or the inability to conceive a child.

Here are some endometriosis statistics. Although it can affect any woman who has monthly periods, it only affects about 10% of women. Some women are completely oblivious to the fact that they have endometriosis because they have no symptoms. Endometriosis is found in 20% of women who have persistent pelvic discomfort and 25% to 50% of women who are infertile.

Let’s learn a little about how endometriosis develops.

Normal endometrial tissue (womb lining) sheds and flows through the cervix as “menstrual blood” throughout each menstrual period. Menstrual blood and endometrial cells travel via the fallopian tubes and into the abdomen in most women. Endometriosis occurs when the body fails to eliminate endometrial cells and they begin to proliferate outside the uterus. It’s unclear why some women are able to discharge endometrial cells from their abdomens while others are unable to. One possible explanation is that the immune system’s function has changed.

No one knows why many (but not all) endometriosis patients experience pain. Pain is caused in some way, perhaps by local irritation or communication between the endometriosis and the neurological system. Estrogen stimulates both the normal endometrium and endometriosis. Estrogen is generally generated in the first half of the menstrual cycle to thicken the uterine lining. Estrogen can also promote endometriosis growth in and around the pelvic cavity.

In the second part of the cycle, progesterone is produced to assist prepare the uterine lining for the implantation of a fertilized egg or embryo.

Progesterone production decreases when there is no pregnancy, leading the endometrium to shed. Implants of endometriosis in other parts of the body can cause bleeding and add to pelvic discomfort sensations.

It’s unclear how endometriosis leads to infertility.

Even minor endometriosis is likely to create alterations that obstruct egg collection, fertilization, embryo passage through the fallopian tubes, or embryo implantation in the uterus.

Scar tissue involving the tubes and/or ovaries can obstruct egg release or pickup, or prevent sperm from reaching the egg in severe situations.

How is endometriosis diagnosed?

The presence of copious and severe menstrual bleeding in a woman’s past can provide numerous indicators, but it is not enough to make the diagnosis. Your doctor will inquire about other women in your family in addition to your symptoms and menstrual cycles. Endometriosis is more frequent in women who have a mother or sibling who has it.

A pelvic exam is a crucial aspect of the diagnosing process.

During a vaginal and rectal examination, your doctor may be able to feel nodules that are suggestive of endometriosis.

Ultrasound can help with diagnosis by revealing blood-filled ovarian cysts, which could be endometriomas.

Finally, a woman’s response to medical treatment may reveal whether or not she has endometriosis. The presence of endometriosis is suggested by the relief of chronic pelvic discomfort with drugs, although this is an erroneous way of diagnosis.

Surgery is essential for a definitive diagnosis of endometriosis. The most common surgical method is laparoscopy, or “band-aid surgery” through the navel. Your doctor can see endometriosis implants inside your pelvis using a telescope instrument. In some cases of endometriosis, open abdominal surgery is required. When endometriosis is suspected outside the pelvis, or when the surgeon is unsure when visualizing lesions in the pelvis, a surgical biopsy to remove a tiny piece of tissue is required to confirm the diagnosis.

What does endometriosis look like?

Endometriosis is diagnosed during surgery and can occur in a variety of ways.

Small, flat or elevated areas of superficial endometriosis can be found on the pelvic surface. Clear, white, brown, red, black, or blue patches can be found. In areas where endometriosis has spread, scar tissue can form between structures and tissues. Deep endometriosis manifests itself in the afflicted tissue as nodules of varied sizes. Endometriomas, or ovarian endometriosis cysts, are filled with a thick brown fluid and are referred to as “chocolate cysts.”

Endometriosis lesions are frequently biopsied and examined under a microscope to confirm the diagnosis.

Following surgery, your doctor may use a grading system to document the severity of the condition by charting the locations and amounts of endometrial tissue outside the uterus. Scores for minimal and mild endometriosis vary from 1 to 15, whereas scores for moderate and severe endometriosis exceed 15. The moderate and severe forms of endometriosis can have the most serious effects on a woman’s ability to conceive.

How is endometriosis-related pain treated?

Endometriosis is typically treated by surgery, with the goal of removing as many endometrial implants as feasible. Several procedures can be used to remove superficial endometriosis. Electrosurgery, laser, ultrasonic scalpel, and surgical scissors are examples of these. To remove deep endometriosis from an affected organ, such as the ovary, surgery is usually required.

Endometriosis can be treated using a variety of medical procedures. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are commonly used to relieve pain. Narcotic medicines are occasionally used to treat severe pain, but they should be taken with caution because they can be addictive.

Hormone therapy can assist with endometriosis pain, but it should only be used by women who do not want to have children.

The thickness of the endometrial lining and the amount of menstrual flow are reduced by birth control pills. Estrogen and progestin are two hormones found in most birth control tablets. The thickness of the endometrial lining is likewise reduced by progestin-only medications. A tablet, an injection, or an intrauterine device can all be used to administer progestins (IUD). After quitting birth control tablets and progestins, endometriosis symptoms frequently reappear.

Another sort of therapy is GnRH analogs. These medications work by lowering estrogen levels in a woman’s body, which causes the menstrual cycle and ovulation to end. An injection of leuprolide acetate is an example of a GnRH analog. Hot flashes and bone loss are common side effects of these medicines, which are similar to those of menopause. Low-dose estrogen and progestin therapy, sometimes known as “add-back” therapy, helps to prevent these side effects.

Many women find that changing their lifestyle can help them cope with many of the symptoms of endometriosis.

Regular exercise and weight loss can help maintain estrogen levels low by reducing body fat.

Avoiding big amounts of alcohol and caffeinated beverages is also beneficial.

Other causes of pelvic and abdominal discomfort should also be investigated and treated.

Chronic pelvic pain can have a variety of causes, and many causes are frequently present in the same woman.

The bladder, the intestines, or the muscles can all cause pain. Other causes of pelvic and abdominal discomfort should be looked into and treated as well.

How is endometriosis-related infertility treated?

Surgery is a treatment option for women who desire to become pregnant, especially those who have moderate or severe endometriosis. Any of the approaches we’ve already mentioned can be used to eliminate superficial endometriosis. Scar tissue is eliminated as much as possible to allow the internal organs to move freely. Endometriomas of the ovary can be surgically removed. Some women’s fertility will improve as a result of this.

In women with endometriosis, medical treatment with hormones that restrict the ovaries has not been reported to increase fertility. Painkillers, on the other hand, may help you feel better.

The ovaries can be stimulated with clomiphene citrate pills or injections of the hormone FSH to boost hormone levels. These medicines increase the likelihood of multiple pregnancies by causing several eggs to be released during each cycle. These medicines are frequently used in conjunction with an IUI treatment, in which the partner’s sperm is cleaned and delivered directly into the uterus. This increases the quantity of sperm that come into contact with the egg(s) and thus the likelihood of conception.

In vitro fertilization (IVF) is the most effective, but also the most costly, treatment for endometriosis-related infertility.

When previous therapies have failed, IVF is suggested.

In IVF, injectable hormones are used to stimulate the ovaries, and ultrasonography and blood hormone levels are used to track the eggs’ growth. When the eggs are mature, a transvaginal surgery is used to extract them. In a laboratory, the eggs are fertilized with sperm. Embryos that develop are usually placed directly into the uterus.

IVF pregnancy rates are similar for women of similar ages, whether or not they have endometriosis.


Endometriosis is a prevalent source of pain and/or infertility in women, despite the fact that many women experience no symptoms. Endometriosis-related pain may respond well to medical or surgical therapy. Other coexisting causes of pelvic discomfort should be evaluated and treated, especially if endometriosis treatment does not reduce the pain. Women who want to get pregnant but have moderate to severe endometriosis can have surgery, which is usually done laparoscopically. After endometriosis therapy, many women will be able to conceive. Endometriosis hormone therapies usually inhibit pregnancy. Advanced infertility treatment procedures, such as IVF, may be required in some circumstances.

Talk to your doctor about your specific treatment choices if you have questions about endometriosis.

Does endometriosis surgery leave scars?

Endometriosis is a condition in which the uterine endometrial glands and stromal component are visible outside the uterine cavity in women of reproductive age. Endometriosis in a surgical scar is a very uncommon complication following obstetric and gynecologic procedures. Scar endometriosis is characterized by cyclic pain and a growing tumor in the scar following obstetric or gynecologic procedures. We report 24 examples of scar endometriosis, with a focus on variations of clinical symptoms, differential diagnosis, treatment approaches, and prevention.

How much is a hysterectomy out of pocket?

  • A doctor’s appointment copay, perhaps a hospital admission charge of $100 or more, and coinsurance of 10% to 50% for the surgery are common out-of-pocket costs for patients with health insurance. When a doctor recommends a hysterectomy as medically necessary, it is usually covered by health insurance.
  • A hysterectomy might cost anywhere from $10,000 to $20,000 or more for those who do not have health insurance. A vaginal hysterectomy with or without removal of tubes and ovaries, for example, costs roughly $6,800-$13,400 at Saint Elizabeth Regional Medical Center in Lincoln, NE, without adding the doctor’s fee, which generally adds several thousand dollars to the cost. The cost of a laparoscopic vaginal hysterectomy, which includes the removal of the fallopian tubes and ovaries, ranges from $10,750 to $21,750. An abdominal hysterectomy at Wright Medical Center in Iowa costs around $15,500, including a $2,250 doctor fee. With an uninsured discount, Kapiolani Medical Center for Women & Children in Hawaii charges around $15,300-$17,800; but, if the surgery is for cancer, charges might rise to around$23,700 or more. A standard or laparoscopic vaginal hysterectomy with removal of tubes/ovaries costs over $17,500 at Baptist Memorial Health Care in Memphis, while a total abdominal hysterectomy costs around $19,200.
  • There are three forms of hysterectomy: partial, which removes the upper portion of the uterus but leaves the cervix in place; total, which removes both the uterus and the cervix; and radical, which removes the uterus, cervix, tissue on both sides of the cervix, and the upper area of the vagina. The doctor may consider removing the ovaries and/or fallopian tubes as well, depending on the cause for the hysterectomy.
  • Hysterectomies can be done in a variety of methods, including abdominally (where the doctor makes an incision in the belly) or vaginally (when the doctor removes the uterus through the vagina). They can be performed using regular surgical techniques or laparoscopically, which is a less intrusive option.
  • A standard hysterectomy takes four to six weeks to recuperate from, but a minimally invasive hysterectomy, such one performed laparoscopically, takes three to four weeks.
  • After a hysterectomy, regardless of age, the patient will enter menopause if the ovaries are removed. Hormone replacement medication, which can cost anywhere from $10 to $85 per month, is frequently prescribed.
  • Many doctors and hospitals offer uninsured/cash-paying patients discounts of up to 40% or more. The Washington Hospital Healthcare System in California, for example, gives a 35% discount. Uninsured patients can get a 40% discount if they pay in full within 30 days, or a 30% discount if they pay in full within 90 days at Kapiolani Medical Center for Women & Children.
  • A board-certified gynecologist with substantial expertise performing hysterectomies should do the procedure. Make sure the doctor is certified by the American Board of Obstetrics and Gynecology by using the American College of Obstetricians and Gynecologists’ doctor finder by state. Patients considering a certain type of hysterectomy, such as a laparoscopic hysterectomy, should inquire about the doctor’s experience with similar procedures.
  • A board-certified gynecologic oncologist should do the operation if the hysterectomy is being performed owing to malignancy or if it is suspected that a woman having a hysterectomy may have cancer. A gynecologic oncologist finder is available from the Gynecologic Cancer Foundation. Gynecologic oncology is a specialization of obstetrics and gynecology that requires board certification as well as three to four years of extra training and certification after passing a difficult exam.
  • Before deciding whether or not to have a hysterectomy, it is generally recommended that a woman seek a second opinion.