Why Most Endometriosis Surgeons Are out of Network with insurances:The reimbursement crisis

There are well‑documented problems with how insurance and reimbursement work that affect both patients and surgeons. These issues influence access to high‑quality care, costs, and the ability of specialists to remain in network.

1. Poor Valuation of Endometriosis Surgery

Insurance reimbursement systems often don’t distinguish between very basic procedures and highly complex ones:

• Under current billing codes like CPT 58662, insurers treat a brief superficial treatment and a multi‑hour expert excision of deep disease as essentially the same thing in terms of reimbursement.

• This means surgeons are paid the same amount whether the surgery was simple or extremely complex, despite big differences in time, skill, and outcomes.

Because of this, there’s a financial disincentive for surgeons to invest their time and skill in advanced endometriosis care, since they are not compensated proportionately.

2. Lack of Specific Billing Codes

There’s no dedicated insurance code that specifically represents comprehensive endometriosis excision surgery in the U.S. coding system.
As a result:

• Surgeons can’t properly document the severity of disease or the complexity of the operation for reimbursement purposes.

• Insurers may underpay or categorize the surgery as less intensive than it truly was.

Efforts by advocates and professional groups are underway to create more precise billing codes, but those changes are still in progress.

3. Medical Necessity and Prior Authorization Barriers

Even when surgery should be covered, insurers often require:

• Extensive documentation proving that less invasive treatments were tried first

• Prior authorization before surgery approval

This can cause delays in care, denials, and additional administrative work for physicians and patients.

Even after approval, coverage may be limited to specific providers, techniques, or time windows.

4. Out‑of‑Network and Out‑of‑Pocket Challenges

Because of the reimbursement inconsistencies:

• Many endometriosis specialists choose not to participate in insurance networks, since the payment rates are too low relative to the work required.

• Patients may have to go out of network, leading to far higher out‑of‑pocket costs or balance billing.

Personal accounts from patients report battles with claims, denials, and confusion over how procedures are billed, which can delay or block reimbursement.

5. Gender Disparities in Medical Reimbursement

Broader analyses of reimbursement rates show that female‑specific procedures tend to be undervalued compared with male‑specific procedures of similar complexity.
This systemic undervaluation contributes to lower compensation for surgeries like endometriosis excision relative to other surgical specialties.

6. Impact on Access and Quality of Care

These reimbursement problems mean:

• Fewer surgeons are willing to offer comprehensive excision surgery in‑network

• Patients may delay surgery or choose less effective approaches

• Specialized multidisciplinary care centers may struggle financially

Overall, financial and coding structures influence clinical practice, sometimes to the detriment of patients and quality outcomes.

In Summary

The current reimbursement issues in endometriosis surgery stem from:

• Inadequate and nonspecific insurance codes for complex excision

• Low and inequitable compensation for time‑intensive procedures

• Prior authorization requirements and variable definitions of medical necessity

• A system that fails to recognize the true complexity and benefit of advanced endometriosis surgery

These factors create barriers for patients seeking care and discourage specialists from offering high‑quality endometriosis surgery within insurance networks.

For the calendar year 2026, Medicare reimbursement for CPT 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface) ,the main CPT code used for endometriosis surgery of variable complexities is $735-$815 ,That reimbursment include all visits in the first 90 days after surgery.if multiple other procedures done at the same time ,the second procedure is discounted by 50%.

"When you adequately reimburse a surgeon, you are not simply paying for the hours in the operating room. You are paying for the decade of training that preceded them, the thousands of cases that informed them, and the lifetime of commitment that sustains them."

Salman Okour,MD