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Will Health Insurance Pay For Essure Reversal Or Essure Removal At A Personal Choice?

Essure Reversal and Essure Removal
Health Insurance Reimbursement

Dr. Monteith is a participating provider with Blue Cross Blue Shield, Cigna, and Aetna.

If you are a participating member with one of these three health insurance companies, you may be able to obtain partial reimbursement for Essure removal or Essure reversal surgery.

In general, most health insurance companies will not pay to reverse tubal ligation.

As a result of the increasing number of women experiencing complications from Essure, some health insurance companies will reimburse for Essure removal or Essure reversal.

Essure removal vs Essure reversal

Both procedures involve removing the Essure devices but what is done to the fallopian tubes after the devices are removed is different for each procedure.

  • Essure removal is a surgical procedure to help women who are having symptoms after Essure, want the Essure devices removed, but do not want to become pregnant.
  • Essure reversal is a surgical procedure to help women who want their Essure devices removed and who want to become pregnant naturally.

Some patients have been able to obtain partial reimbursement when having Essure removal or Essure reversal surgery at A Personal Choice.

How to determine if health insurance will pay for Essure reversal or removal?

The best way to determine if your health insurance company will pay for your surgery is to call your health insurance company and ask.

They will ask for the ICD-10 diagnosis code, CPT surgical procedure code, and Place of treatment code before they can determine if the procedure is covered. Below are the ICD-10, CPT codes, and Place of treatment codes for Essure removal and Essure reversal procedures.

Essure coil removal only
This series of codes are for patients who want Essure removed and do not want to become pregnant.

  • ICD-10 code for bilateral tubal occlusion N97.1
  • CPT code for Essure coil removal 49000
  • Place of treatment code 11

Essure reversal
This series of codes are for patients who want Essure reversed and want to become pregnant.

  • ICD-10 code for bilateral tubal occlusion N97.1
  • CPT code for tubo-uterine implantation 58752
  • Place of treatment code 11

Steps for reimbursement for Essure removal/reversal at A Personal Choice

Patients having surgery with Dr. Monteith are expected to:

  1. Verify  coverage for Essure removal or Essure reversal using the above codes before surgery
  2. Pay for surgery in-full at the time of scheduling
  3. Request A Personal Choice bill your insurance on the day of your surgery (only if your insurance company said they would cover your surgery)

A Personal Choice will submit your claim to Blue Cross Blue Shield, Aetna, or Cigna after your surgery is completed.

If your health insurance company provides reimbursement then A Personal Choice will mail your reimbursement check to you after your surgery is completed. In general, most reimbursements are received and mailed to the patient within four (4) to six (6) weeks of having your surgery completed.

In general reimbursements have ranged from 0% to 50% of the entire surgery cost. If you are expecting full reimbursement then you will be greatly disappointed.

Health Insurance Reimbursement: Important points to understand

All patients must pay in full before having surgery with Dr. Monteith.

After surgery is completed, A Personal Choice will file your claim (only for patients who are members of Blue Cross Blue Shield, Cigna, and Aetna).

If your health insurance company reimburses you for surgery, they will send reimbursement directly to A Personal Choice and A Personal Choice will send you a check for the same amount.

Most health insurance companies will not pay for surgery. A few will provide partial reimbursement. We have observed reimbursement rates ranging from 0% to 50%.

Top 3 reasons why you may not get reimbursement for Essure reversal/removal

Your health insurance company may inform you your procedure will be covered.
Please be aware this information is not always correct. Ultimately the insurance company reserves the right to make the final determination after services are rendered.

Reason #1: Wrong information

There are several reasons why you may be given the wrong information:

  • Health insurance agents are sometimes inexperienced
  • Health insurance agents may not fully understand the procedures required
  • Health insurance agents may be provided the wrong treatment codes
  • Health insurance agents may incorrectly assume the procedure is being performed in a hospital

Reason #2: Wrong procedure

Essure reversal is done to become pregnant again and is considered an elective (non-life threatening) fertility procedure. Most health insurance companies don’t pay for fertility treatment and will not cover Essure reversal.

Essure removal is done for symptoms. Health insurance companies recognize there are immediate complications from Essure in some patients and are more willing to cover Essure removal.

If you have a tubouterine implantation to reverse Essure then health insurance companies will recognize this as a procedure to treat infertility and they will ultimately deny coverage.

Reason #3: Wrong place of treatment

Many health insurance companies will reimburse for Essure removal….but only if the treatment is done in a hospital. Often the health insurance company is expecting you to have either a hysterectomy or complete fallopian tube removal in a hospital.

1. Can A Personal Choice provide an itemized list of services?

Health insurance companies will often request an itemized list of services. We cannot provide a itemized list of services or a breakdown of charges. Why?

Health insurance companies will only recognize and provide reimbursement if the itemized list of services comes from a hospital.

2. Can you change the codes to help with reimbursement?

No. This is unethical and potentially illegal. We will not change codes once they have been provided on your original documentation.

3. Can you provide a letter stating Essure removal was medically necessary?

No. Only a doctor who has evaluated and treated you over time can provide such documentation. Your primary care provider or the doctor who inserted your Essure devices must provide you with documentation required to support the medical necessity of your Essure removal.

4. What if I don’t have Blue Cross Blue Shield, Aetna, or Cigna?

If you are not a member of these plans then you will have to request reimbursement directly from your health insurance company after surgery has been completed. A Personal Choice will provide you with an operative note, billing codes, and a receipt for payment.

What if you want insurance to pay 100%?

If your health insurance company is telling you they will pay 100% of your surgery (and you believe them) then they may only pay 100% if your surgery is done in a hospital. You should not have your surgery at A Personal Choice. Instead you will need to find a doctor who can remove your Essure devices in a hospital setting with hospital billing.

If you have Essure removal in a hospital you should make sure the doctor has experience with Essure removal. Doctors with limited experience are more likely to perform a hysterectomy to remove Essure or leave Essure fragments due to improper removal techniques.

If you want Essure reversal there are very, very few doctors who are actually reversing Essure for patients in a hospital setting.

Removing Essure Is Not Reversing Essure!

We are seeing a steady increase in patients who have not become pregnant after Essure removal by their local doctors.

Many patients are willing to take a chance and have Essure removal in a hospital by their local doctors because their health insurance will pay for it. Many of these patients mistakenly believe they will become pregnant after the devices are just simply removed.

Unfortunately pregnancy will not occur after removal of the devices (even if the tubes are rejoined) because the tubes will spontaneously heal closed after the Essure devices are removed. Just like when you remove a piercing, the hole will close up once the piercing is removed.

If you want to become pregnant then you will need Essure reversal and tubouterine implantation (Essure reversal).