New procedure for endometriosis research via Ultrasonography included in the CBHPM and in the mandatory coverage list of the ANS

As requested by the Brazilian College of Radiology and Diagnostic Imaging (CBR), at the meeting of the Permanent Technical Chamber of CBHPM held on October 7, 2019, the National Commission of Medical Fees and specialty societies approved the inclusion of procedure 4.09.01.85 -8 – US – Endometriosis research, which was introduced in the 2018 CBHPM, according to CNHM NORMATIVE RESOLUTION No. 042/2020. On August 26, 2020, pursuant to official letter No. 62/2020/COMEC/GEAS/GGRAS/DIRAD-DIPRO/DIPRO responding to the request for clarification regarding the mandatory coverage of the US Procedure – Endometriosis Research (40901858), with the wording below, confirming the mandatory coverage of the procedure by health insurance companies for supplementary health plan beneficiaries. “In attention to the e-mail, dated August 1, 2020, issued by Assessoria Econômica – Colégio Brasileiro de Radiologia e Psicologia por Imagem, in which it requests clarification regarding the mandatory coverage of the US Procedure – Endometriosis Research (40901858), recently included at CBHPM 2018, we have to clarify: Preliminarily, we remind you that ENDOMETRIOSIS, according to Health Sciences Descriptors - DeCS/Bireme/PAHO/WHO, is a condition classified within the Diseases of the Female Genitals, in which the functional endometrial tissue is present outside the uterus. It is often restricted to the pelvis involving the ovary, ligaments, cul-de-sac and the uterine bladder peritoneum. We inform you that the investigation of endometriosis by ultrasound is included in the procedures included in the list of ULTRASONOGRAPHY OF THE TOTAL ABDOMEN; ULTRASONOGRAPHY OF THE FEMALE LOWER ABDOMEN; ULTRASONOGRAPHY OF THE FEMALE URINARY TRACT; COLOR DOPPLER OF ORGANS OR STRUCTURES (INCLUDES HEART); TRANSVAGINAL ULTRASONOGRAPHY (INCLUDES FEMALE LOWER ABDOMEN), that is, they can be mobilized for this purpose, therefore, they have mandatory coverage by private health care plans. In this sense, the inclusion of the procedure “US – Pesquisa de endometriosis (40901858)” in the Brazilian Hierarchical Classification of Medical Procedures – CBHPM 2018, published in CNHM Normative Resolution No. 042/2020 of 01/30/2020, is included in the aforementioned procedures , therefore it has mandatory coverage by health plans. Additionally, we clarify that the operator of private health care plans is free to form a network of health service providers, either own or contracted, and must be compatible with the demand and the coverage area of the plan, capable of meeting the beneficiaries within the regulatory deadlines, according to the rules of RN nº 259/2011, and the collection of amounts and/or professional fees must be contracted between the operator of private health care plans and the provider of health services, for the purpose of complying with the mandatory coverage, as specified in RN 363/2014.” At CBHPM, considering its complexity and scope, Size 6A, UCO 17.06 and 0.5100 M2 of radiological documentation were defined. The OBSERVATION code 4.09.01.99-8 – Referring to the procedure was also created in the chapter, establishing that for the same care for the same diagnostic hypothesis the procedures below are exclusive, that is, they cannot be performed to meet the same diagnosis: 4.09. 01.18-1 – US – Female lower abdomen (bladder, uterus, ovaries and appendages), 4.09.01.12-2 – US – Total abdomen (upper abdomen, kidneys, bladder, aorta, inferior vena cava and adrenals), 4.09.01.76- 9 – US – Urinary system (kidneys, ureters and bladder), 4.09.01.38-6 – Color Doppler of an isolated organ or structure, 4.09.01.30-0 – US – Transvaginal (uterus, ovary, appendages and vagina). We recommend that the Diagnostic Imaging and Radiology services identify in their clinics who are the doctors who perform the procedure to start the accreditation process with the health operators in their region. It is interesting that the specialist doctor, who performs the procedure, gets in touch with the main requesting physicians to talk about the proper application of the procedure and take the opportunity to guide them in the correct form of the description in the medical request. While the procedure is not accredited with the healthcare provider, the clinic can offer beneficiaries as a private table, since it does not have accreditation because it is a new procedure. CBR Economic Advisory