Endometriosis is a genetic condition that affects individuals with a uterus. The formal definition is “endometrial glands and stroma existing outside the endometrial cavity.” Essentially, it is tissue that resembles the endometrium (the lining of the uterus), that exists in other places. Most often, it is found in the pelvic peritoneum, or the lining of our abdominal cavity, but can be found in many locations. Endometriosis can cause and contribute to pain, inflammation, and infertility.

We perform a wide excision in centimeters with preservation of vessels and nerves. This is preferred over the excision of small areas (millimeters). Endometriosis matures at different rates in each individual person. It is difficult to know microscopically how far the endometriosis cells exist outside of the visible disease. 

Excision of endometriosis is the technique by which the disease is removed by cutting it out. This allows the expert surgeon to remove endometriosis entirely. Excision also facilitates the removal of the disease while leaving the reproductive organs in place. Excision of endometriosis is a specialty skill rarely found amongst gynecologists, but it offers the highest likelihood of both pain relief and preservation of fertility.

Adenomyosis is essentially endometriosis of the uterine myometrium (muscle layer of the uterus). Possible symptoms of adenomyosis may include chronic pelvic pain, dyspareunia (painful sex), dysmenorrhea (painful periods), and heavy or prolonged periods.

Yes! Dr. Mosbrucker, Dr. Newville, and Dr. Jaggi work together to determine the best surgical plan for each individual and perform surgeries together at St. Anthony’s Hospital in Gig Harbor, WA. They also work closely with Dr. Linda Pai, a highly skilled general surgeon, in patients who have severe bowel or diaphragmatic disease, etc.

PEPS offers the Gold Standard for treatment of endometriosis, which is excision. Excision is the removal of the diseased tissue and the surrounding border. The diseased tissue is removed until healthy normal tissue is encountered. This further reduces the risk of recurrence. Please reconsider surgeon if they perform ablation/burning of endometriosis. If performed by a skilled specialist, then the recurrence/persistent disease risk is very low. Ablation will ONLY burn the surface of the disease. It does not remove the diseased tissue. 

We do all the above. Photo documentation and close-up views of the peritoneum are more important than potential damage of an inexperienced surgeon.

Please note: If a surgeon is not experienced with excision of endometriosis, then they should not proceed with surgery.

Yes. Individual labeling of specimens excised is important for disease location. If patients have undergone ablation or biopsies (millimeters), then knowing the location is helpful for future surgeons. 

It is not helpful to drain an endometrioma and it usually makes everything worse. They will usually fill back up and may cause damage to the fallopian tube beyond repair. The best treatment is excision of the endometrioma entirely and the cyst wall. If you are working with an REI (reproductive physician), then a joint decision between you, the endometriosis surgeon, and REI should occur prior to surgery regarding the surgical plan. When an endometrioma is removed, it involves a process similar to removing the pulp from an orange. Closing the ‘dead’ space allows re-approximation of the edges of the ovary. The closure helps with hemostasis (stop any bleeding) and re-establishment of normal ovarian structure. Suspending (‘tying’) the ovary to the round ligament will help to prevent the ovary from sticking to the sidewall/bowel/uterus/cul de sac. If IVF is in the future, then a temporary ovarian suspension may be performed to allow future access to ovaries for egg retrieval.

Depending on your location and hospital specialists, it may be difficult to have a team who specializes in endometriosis excision. At PEPS we have a multidisciplinary team approach and work closely with Dr. Linda Pai, a highly skilled general surgeon, in patients that have severe bowel or diaphragmatic disease, etc. It is best to have a plan in place, instead of attempting to remove bowel endometriosis without the proper backup when needed. 

You will receive a copy of your operative and pathology reports, along with surgical pictures if any. It is best to keep this for your own medical records. It is very important if you undergo future surgeries with another surgeon. Ask your surgeon what the post operative plan is and discuss expectations as it varies per person. Pelvic floor physical therapy is important following surgery if there is any underlying pelvic floor dysfunction or bladder/bowel dysfunction. 

PEPS is not contracted with any commercial health insurer. This means that the services provided at PEPS are “out of network.” To obtain the maximum coverage for you that your health insurance carrier allows, we work with an external billing service.

Our billing service (MedPro) employs patient advocates who will assist you in communicating with your health insurance carrier to access coverage for PEPS out-of-network services. Your cooperation with MedPro may be necessary for PEPS to provide services to you. Generally, there are three scenarios for payment:

1. If your coverage includes “out-of-network” benefits, MedPro will submit the claim on behalf of PEPS to your insurance carrier and request payment directly to the practice as a non-participating benefits assignee.  If your carrier denies the claim or it is not reimbursed adequately and in accordance with your out-of-network benefits, then MedPro may require your assistance in filing appeals and/or having a patient advocate assigned.

2. If your coverage does not include “out-of-network” benefits, MedPro will seek a “gap exception.” A gap exception may be granted by your health insurance carrier when it determines that there is no appropriate in-network provider that can meet your current health care needs; if granted, then your carrier agrees in advance to cover PEPS’ services as if PEPS were in-network.

3. If your coverage does not include “out of network” benefits and your carrier declines to provide a gap exception, then you are solely responsible for payment for PEPS’ services, should you elect to receive them. Financial arrangements will be made on a case-by-case basis at the time of scheduling your surgery.

Uninsured, Self Pay: Our goal at Pacific Endometriosis and Pelvic Surgery is to provide access to treatment options for all patients in need of our highly specialized services, particularly surgical intervention for endometriosis. If you wish to seek treatment at PEPS but do not currently have an active health insurance policy, please arrange a meeting with our staff to discuss the self-pay options that may allow you to continue with an intended treatment plan as advised by our team of medical providers.

Medicaid: PEPS is not currently accepting any new patients with Medicaid or Medicaid replacement insurance plans.

Tricare: We are not currently accepting any new patients with Tricare, subject to change in the future.

Both state and federal laws exist to protect patients from getting unexpected medical bills. More information about these laws can be found online, including on the Washington State Office of Insurance Commissioner’s website 

CLICK HERE for information regarding Balance billing prohibition and consumer cost-sharing. Surprise Billing visit 

The simple answer is that insurance does not pay for complex time-consuming endo excision surgeries. 

Read on if you want the long and complicated answer….

Endometriosis is an invasive disease that penetrates deep into the tissues of the pelvis and beyond. Many studies have shown that excisional surgery yields better results than the commonly used ablation techniques. However, ablation is what is typically taught in residencies and requires only average skills. In contrast, excision surgery is highly complex, necessitating advanced skills that are often not covered in most residencies and fellowships. This type of surgery can be quite time-consuming, with typical stage IV cases taking 4 to 6 hours or more. Nationwide, there are fewer than 200 gynecologists who claim to specialize in endometriosis excision out of approximately 22,000 OB/GYNs.

Why are there so few endo surgeons? One reason is that it is a very difficult complex surgery that takes a long time to master and there are few fellowships in endo-excision surgery. The other is the lack of financial incentives, which creates a barrier for gynecologists who agree that excision is better for patients. Since excision is very time-consuming to learn and pays poorly, there is little motivation to switch from more lucrative procedures, except for those who genuinely wish to do what is right for their patients. Fortunately, some practitioners still follow their hearts and strive to provide the best care, but they are in the minority.

What follows is an explanation of the inner workings of the healthcare system and why Endo surgery is reimbursed so poorly.

Most doctors and healthcare systems have contracts with insurance companies that dictate payment amounts and rules. Doctors agree to accept the fees predetermined by these companies to attract patients through the insurers. The idea is that if they see enough patients, they can afford to charge less for each encounter. However, this approach has turned healthcare providers into “rats on a wheel,” constantly running faster but getting nowhere. This is why most check-up visits last 10 minutes or less, and many believe it contributes to inaccurate diagnoses and inadequate treatment, as there is little time to engage with patients or take a thorough medical history.

Moreover, insurance companies wield significant power, as they set the rules and determine which procedures can be performed and how much they will reimburse. Large corporations often receive more favorable rates than smaller practices, and contracts typically prohibit sharing details among practices. Doctors are also forbidden to unionize, which leaves them unable to coordinate a fair response to the insurers’ practices. This system is pushing many surgeons to pursue the most profitable procedures instead of those that are best for patients. For example, many gynecologists are opting to do office hysteroscopy and endometrial ablations rather than hysterectomies because they are way faster, easier, and paid nearly as much with much less risk. In addition, these simple procedures which take very little skill are reimbursed about two to three times as much as excising endometriosis.

Doctors are compensated based on a coding system known as CPT (Current Procedural Terminology). Each procedure conducted through a large incision (such as a hysterectomy, appendectomy, or bowel resection) has a specific CPT code used for billing. Some common procedures have separate CPT codes for laparoscopic versions, but many do not and only have codes for open procedures. There is one CPT code for laparoscopic surgery for endometriosis, and it is identical regardless of whether excision or ablation is performed. Most of the procedures used to excise advanced stages of endometriosis (like discoid bowel resections, ureterolysis, and ovarian cystectomies for endometriomas) lack specific laparoscopic CPT codes, forcing us to use unlisted codes, which are generalized for laparoscopic procedures. Nearly all insurance companies reserve the right to deny payment for these unlisted codes, resulting in very poor reimbursement for excising endometriosis.

Almost all true expert endometriosis excision specialists are out of network due to these reasons. At Pacific Endo, our goal is not to be unreasonable with our rates but to attain fair reimbursement for the skill, time, and effort required to provide proper care for our patients with endometriosis. While many out-of-network (OON) surgeons are highly skilled, there is a lack of consistency in both skill and pricing. Some OON doctors charge upwards of $20,000 for surgery on early-stage endometriosis and do not entirely remove the disease. We strive to keep our rates low because we believe that effective surgery for endometriosis should be accessible to everyone, not just those with substantial financial means. We are not trying to profit from patients with this challenging disease; we simply seek to remain financially stable as our practice faces ever-increasing expenses.

Uninsured, Self-Pay: To address the needs of our patients without insurance who wish to pay out of pocket for PEPS services, we offer a discounted fee. This discount automatically applies to all medical services provided and is offered at the time of service. For those wishing to have surgery, we offer a bundled rate that includes surgeon fees, pre-op, and post-op care. We also have a billing arrangement with St. Anthony’s Hospital for our surgical patients.  Please ask us for further information.