Most women who have tubal ligations do not have problems.
We all learned in elementary school that ‘most women’ does not mean ‘all women’.
Some women have their tubes tied and have very real problems. These women can have legitimate medical reasons for tubal reversal surgery.
Many women regret tubal ligation because they want to become pregnant again.
One way to get health insurance to pay for it is to make up a medical reason for surgery and have the insurance company pick up the tab. Unfortunately, many health care professionals and patients…. have abused creating medical reasons to get insurance companies to pay for reversal surgery.
Health insurances have caught on to these tricks and have issued blanket administrative policies stating they will not cover reversal… no matter what the reason(s).
Although many women do not have problems after getting their tubes tied… some do have issues.
We have two things to say to you if you want to get your health insurance company to pay for your reversal procedure:
- Good luck
- Be persistent
Some women have been able to get their health care insurance companies to pay, at least in part, for their reversal surgery. Keep reading for more insight and advice.
In our experience, the medical reasons for tubal reversal surgery are often not fully evident until after the reversal surgery has been completed.
So your biggest fight to get them to pay for reversal may have to be saved until after your reversal surgery is finished.
Most common reason for tubal reversal
The most common reason for having tubal reversal is guilt and regret. Many women feel guilty at some point after having their tubes tied.
They had their tubes tied while they were young, in abusive relationships, or had children that were close in age.
The stress of having to care for kids in difficult circumstances is just too much… especially when you do not have much support. As these mothers become older, they often find things change. They are older and wiser. They may be in a new relationship and their new partner is usually more caring and understanding.
With the passage of time, those young children who were close in age at the time of tubal ligation are now older teenagers. Having a 16 year-old and a 15 year-old is not the same as having a 3 year-old and a 2 year-old. Not even comparable!
When the kids get older then empty nest feelings start to creep in. Some women want another child. These feelings quickly turn into regret.
Regret usually leads people to think of ways they can right a past wrong. Approximately 90% of our patients seek reversal to have more children. They simply regret getting their tubes tied.
So without a doubt… tubal reversal because of regret …. is the most common reason women seek reversal of tubal ligation.
Health insurance understands regret: They just won’t pay for it!
Health insurance companies know sterilization regret is common. Most health insurance companies are ‘for profit companies’.
For profit companies exist to make a profit. They are not in business to lose money. Health insurance companies don’t take $20,000 a month from a group of people to consistently have to spend $50,000+ every month on that same group! They would quickly be out of business if they gave out more money every month than they took in.
Health insurance companies are not in business to make you more healthy. This may be a surprise for many who are reading this.
Some health insurance companies try to incentivize you to be more healthy (stop smoking, exercise, lose weight, etc) but other than charging you more because you will cost them more… society and health insurance companies have not figured out a good way to incentivize healthy behavior.
Just like home insurance or car insurance companies…they exist to make money and help you out in the rare case you have a catastrophic situation.
It is true…as long as you pay your monthly premiums they will help with your issues…but only specific issues and only to a certain extent.
If someone damages your car…insurance will pay to get it fixed. If your car is totaled insurance may even pay you ‘fair market value’ for your car…and as we all know the fair market value is never what you paid for the car. It will be hard to total your car and go out and get a brand new version of the same car you were driving unless you come out of pocket for the difference.
The point is this… you can not expect to pay $8,000 a year in car insurance, wreck you car, and expect them to buy you a more expensive $100,000 Mercedes. It just does not work that way.
Why would you expect health insurance companies to be any different? Do you expect this only because the word ‘health’ is before insurance?
Health Insurance Companies Are In Business To Make Profit
Health insurance companies are not going to let you sign up and then immediately start getting costly, non-essential surgeries or treatments.
Long ago health care companies realized health care is expensive and the costs increase every year. They only way they can make a profit is to charge you more every month and/or pay out less money than they take in.
Long ago these companies decided they would not pay for unnecessary surgeries….we call these ‘elective surgeries’. Which means, you ‘elected’ or chose to have this surgery for personal reasons…not medical reasons.
Cosmetic surgery (face lifts, breast enlargement, liposuction, etc) and infertility procedures are often considered elective surgery. They are not medically necessary. They are not required to save your life.
Unfortunately, many healthy insurance companies will not pay for infertility treatments because they don’t see infertility treatments as necessary to save your life.
Some companies (a few…but not many) will only cover infertility treatments but only if you meet certain conditions… basically if the infertility is not due to any fault of yours. Some may only pay for IVF once you pay for tubal reversal surgery and have proof the tubal reversal did not work.
Many health insurance companies determined if YOU made a VOLUNTARY decision to limit YOUR reproduction then why should THEY pay money to correct YOUR poor decision?
So if you understand the above you can more easily understand why health insurance companies are very suspicious of people who try to claim medical necessity.
Medical reasons for tubal reversal surgery
Dr. Monteith is the Medical Director of a Personal Choice Tubal Reversal center in Raleigh, North Carolina.
Dr. Monteith specializes in reversal surgery. He sees many different types of cases and he has definitely seen tubal ligations that cause problems for women. He has identified four main issues that can cause problems for women after tubal ligation.
Ovarian fallopian tube endometriosis after tubal ligation.
1. Endometriosis. Some women will develop endometriosis of the fallopian tubes after tubal ligation.
Most women with endometriosis have no symptoms but many will have pain with their periods or during sexual intercourse. Some women have vague bowel and urinary symptoms that are difficult to diagnose. For reasons unclear to us, many tubal reversal patients with endometriosis will report heavier periods.
Many of these women have no history of endometriosis and many of them had normal findings when their tubes were tied. At the time of tubal reversal, Dr. Monteith will observe endometriosis causing scarring at the tubal ligation sites.
For more information: Tubal ligation and endometriosis: Personal observations
2. Scar tissue. Some women will develop scar tissue after tubal ligation. Most cases of scar tissue will not cause symptoms…but some forms of scar tissue can cause pain.
Dr. Monteith occasionally sees tubal ligation sites abnormally attached to the round ligaments of the uterus, fallopian tube segments attached to the intestines or pelvic side walls, or ovaries that are scarred and stuck to the tubal ligation sites. Many times patients will report relief of pain after surgical correction of these conditions.
3. Foreign body reactions. Dr. Monteith frequently sees women who have adverse reactions to the Essure tubal occlusion devices and fallopian tubal clips.
Essure devices. Essure devices cause problems from 1) possible allergies to metal (most likely the nickel) and 2) perforations of the uterus and/or fallopian tubes.
Blue arrow shows Essure device perforating uterus. Yellow arrow shows closure of fimbrial end of tube.
The photo in this post shows a perforating Essure device (blue arrow). This complicated Essure insertion likely caused infection of the tube. This infection resulted in the closure of the fimbrial end of the tube and the fallopian tube filled with pus (yellow arrow). This is called a pyosalpinx.
The opposite Essure device (not seen in this photo) was partially in the tube but mostly in the uterine cavity. Esure devices in the uterine cavity can often cause painful heavy periods.
The patient in who this photo was taken had prolonged pain and recovery from the Essure insertion but also had systemic symptoms suggesting allergy to the metals in the device. The devices remained in place for several years before removal.
Prior to surgery her imaging was consistent with a successful procedure. As we have said above sometimes medical reasons for tubal reversal cannot be accurately diagnosed until after surgery has been completed.
Tubal clips. Some women will have problems from tubal clips. Most tubal clips do not seem to cause problems but sometimes tubal clips can be stuck to the round ligament. The round ligament has a neuromuscular bundle that can contribute to some cases of chronic pelvic pain.
Sometimes tubal clips clips can fall off, migrate, and embedded in the peritoneum of the pelvis, or are stuck to the intestines, back wall of the pelvis or abdomen and these clips can cause pain. Some women report allergic symptoms from clips suggesting some reaction to a metal component of the clips.
We have observed some women having enlargement of the proximal portion of the tubes and extensive fibrosis of the fallopian tube muscle. Many of these patients may have endometriosis in the tubal muscularis that developed after placement of the tubal clips.
4. Fertility dysmorphia. This term was created by tubal reversal surgeon Dr. Monteith based on years of experience in reproductive health. You will not find this concept anywhere else. If you don’t believe this then Google “fertility dysmorphia” and see what comes up… basically nothing.
Dr. Monteith has observed some women develop depression, anxiety, grief, and regret from the loss of their fertility. Sometimes depression and anxiety will lead to other bodily issues.
These women have voluntarily, some involuntarily, given away what makes them uniquely a woman…the ability to create life.
For some women this has a profound, long-lasting impact on their self-perception during their fertile reproductive years. These feelings may be smoldering underneath the surface for years and may be erupt when the women gets into a new relationship were fertility becomes an issue.
Although it sounds crazy, all you have to do is look at the breast cancer medical literature for more studies on body dysmorphia after breast cancer and mastectomy treatment. Women who have breast cancer requiring removal of their breast can sometimes have profound feelings very similar to the feelings of women who have tubal ligation.
Breast cancer patients usually get more attention because they 1) have cancer (a life threatening disease) and 2) have a surgery which causes outward visible disfigurement which is a constant visual reminder for them and for others of their disease and their condition.
In many ways women who have tubal ligations have a similar impact upon their self-perception… minus the life threatening aspect.
Women with tubal ligation have a life changing procedure with non-visible inward disfigurement of their reproductive organs that make them uniquely a woman. Any reminder they cannot have more children triggers feelings about their self-perception.
Patients do not usually have psychological issues when their gallbladders, appendixes, or spleens are removed but when you start removing organs of sexuality and fertility then we begin to see some patients suffering from psychological issues.
There is a wealth of literature that describes the impact of breast cancer, mastectomy, and breast reconstruction on patients who have breast cancer. One particular article describes how breast cancer patients improve mentally after breast reconstruction: Sexuality, depression, and body image
If you take the time to read the breast cancer, mastectomy, and breast reconstruction literature you will see a lot of interesting similarities between mastectomy patients and tubal ligation patients.
Easiest way to get health insurance to pay for surgery?
If you are legitimately having a problem from your tubal ligation then you should have a history of documented visits to your doctor detailing your symptoms and treatments.
If you have surgery for your symptoms and your doctor performs a procedure that is well-know to treat most gynecologic disease conditions then your health insurance will most likely pay for your treatment.
Most health insurance companies will easily pay for you to have:
- Removal of your fallopian tubes (total salpingectomy)
- Removal of your ovaries (oophorectomy)
- Removal of your uterus (hysterectomy)
Health insurance companies understand these are well recognized procedures that treat gynecologic problems but also do not allow you to have more children.
All of the above are serious gynecologic surgeries performed to treat serious gynecologic problems. Your health insurance company will usually not deny claims that have the procedural codes for the above surgeries.
So the easiest way to get health insurance to pay for your surgery is to have procedures that remove scar tissue and treat endometriosis by removing your tubes, ovaries, or uterus. The procedures that totally remove parts of or all of your female organs are the procedures that more readily get reimbursed. This may not sound good… but it is true.
Tubal reversal can help some women with their symptoms…but the surgery also helps you get pregnant.
Health insurance companies realize this little game of trying to claim medical necessity. They are on to it and this is why most will not pay for tubal reversal surgery.
Essentially they are saying…you may be having an issue but we want to see proof of a definitive treatment rather than a treatment that may treat your problems but also allows you to restore your fertility.
Advice on getting health insurance to pay for tubal reversal
To increase your chances of health insurance paying for tubal reversal then you should do the following.
Have a documented history of your problems. If you are having problems as a direct result of your tubal ligation then you should have had several doctors visits documenting your problems in detail. Not just one visit over 10 years…but several visits and evaluations. These visits, doctor’s opinions, and treatments should be clearly documented in your records.
Call the insurance company and speak to a representative. You will need to explain your symptoms and tell them you are seeking coverage for tubal reversal.
- If your tubes were clamped, tied, cut, or burned then you will need a tubotubal anastomosis procedure. The procedure code for tubotubal anastomosis is CPT 58750. You will need to ask them if the will pay for the CPT code 58750.
- If you had the Essure or Adiana procedure then you will need to code for tubouterine implantation procedure. The procedure code for tubouterine implantation is CPT 58752. You will need to ask them if the will pay for the CPT code 58752.
Keep in mind the person you get on the phone the first time…will not be who you will speak to the second or the 30th time!
Some will be poorly trained/educated and give you inaccurate information. Always have documentation of your conversation. Ask them to email you their answer or put the communication in your file.
A few may tell you the truth…go out on a limb and say that is never paid for. Most will probably tell you to send all your paperwork for preauthorization and they will determine if it will be paid for later.
Keep documentation of whoever you speak to. Save all emails. You may need to provide this information as evidence to get your reimbursement.
If they tell you “Yes this will be covered” before your surgery then they should pay for it. You should also realize that after surgery is complete and you send them all your information they may end up denying coverage….but at least if you have documentation then that gives them less of a denial defense.
Often they will change their minds after your surgery. The most important piece of advice…is never, never, ever, ever give up. Be persistent. You may have to fight them for 6 to 18 months after your reversal surgery before you will see any payment.
Remember: Never give up! Often this is a war of who will give up first!
Letter of documented medical necessity from your doctor. If your health insurance company requires it then you may need a letter of medical necessity.
Your primary care doctor should be willing to support your symptoms, failed treatments, and recommendation for tubal reversal surgery. This letter can only be provided by your primary care doctor… or the doctor who is most familiar with your symptoms.
Reversal surgery with Dr Monteith
We specialize in reversal of tubal ligation. Most of our patients have reversal to become pregnant. Some have reversal only for treatment of their symptoms and soon after their reversal surgery they immediately have their partners get vasectomy.
Many of these women have been to countless number of doctors without any meaningful diagnosis. Many of these women get reversal and then immediately have their partners get vasectomy. These women 100% without a doubt do not want to become pregnant.
More information: Symptoms after tubal ligation
If symptoms started soon after tubal ligation and no other cause can be identified most of them report improvement after reversal surgery…even if everything is totally normal at the time of reversal surgery.
The video provides a brief overview of what we do for our patients.
Reversal for medical reasons: What we can not do
We cannot provide you with a letter of medical necessity and we cannot argue your case for you directly to your health insurance company. Why?
Talk to your health insurance company. This is your company. You picked it. You signed the contract. You pay them every month. Any plans or agreements are between you and them. We can’t let interactions with them drag us down.
We have dealt with health insurance companies before. They call us…we always answer. We call them…we are on hold for a long time, always get someone different, and never get the same answer. Been there… done that… got the t-shirt…..ain’t doing that again.
Provide letters of medical necessity. If your tubal ligation was 10 years ago and you have been having problems then there is usually a well documented paper (or electronic) trail between you and your doctor.
Your primary care doctor should know you and what you have been going through the best. They are the best ones to write you a letter of medical necessity.
We are constantly contacted from all across the English speaking world for information and request for tubal reversal. Patients travel to us for reversal surgery and stay 2 nights and 3 days. They then return home.
It is not possible to provide documentation for all the potential patients who may want reversal surgery. Many people who contact us will never come to us for surgery. We cannot be in a position of providing documentation to all of these potential patients who have no plans on utilizing us for their surgery.
Writing a letter of medical necessity implies we know what has been going on with you since your tubal ligation and we are attesting to the validity of your concerns. Since we only meet patients the day before surgery it is not realistic that we can attest to knowing your daily struggles since the day your tubes were tied. To create such a letter would not be ethical.
The reality is your local doctor should know your situation in detail and would be the best person to write you a letter of medical necessity.
Reversal for medical reasons: What can we do?
If you want reversal with us then we will gladly help you.
We can provide you with a high quality reversal surgery in a safe, supportive health care setting. We can attend to you with staff who are supportive and knowledgable. You can be confident you are getting a skilled surgeon who will spend time with you during your consultation, surgery, and post operative visit.
All patients of A Personal Choice get a copy of their payment receipts, tubal ligation operative report, and Dr. Monteith’s medical recommendations. You can also use this information we provide you and send it to your health insurance company to help you substantiate your medical reasons for tubal reversal surgery.
If you have any questions then call our office at (919) 977-5050 and one of our staff should be able to help you.
