Essure Reversal and Essure Removal
Health Insurance Reimbursement
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 may provide reimbursement 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 also want to become pregnant naturally.
Some patients have been able to obtain 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 obtain preverification.
Your health insurance representative will ask for the ICD-10 diagnosis code and CPT surgical procedure codes before they can determine if the procedure is covered. Below are the ICD-10 and CPT codes commonly used for Essure removal and Essure reversal procedures at A Personal Choice.
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
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 tubouterine implantation 58752
Preverification: Do you need a letter of medical necessity?
Sometimes your health insurance company will pay for surgery but only if a doctor provides a letter of medical necessity.
A letter of medical necessity is a letter provided by the doctor supervising your care. This letter describes your symptoms, your diagnosis is, and why Essure removal or Essure reversal surgery is medically required.
Any pre-certification or pre-authorization required by your health insurance company is the responsibility of the patient. Since our surgical fees are all-inclusive, we do not provide a cost breakdown to health insurance companies. We are unable to file insurance claims for reversal surgery.
If your health insurance requires a letter of medical necessity then A Personal Choice or Dr. Monteith will not be able to provide a letter or medical necessity either before or after reversal surgery.
Your primary care doctor…or the doctor evaluating you for possible Essure related symptoms…. will have to provide the letter documenting your symptoms and explaining the medical necessity of your surgery.
Steps for reimbursement for Essure removal/reversal at A Personal Choice
Patients having Essure reversal or Essure removal surgery with Dr. Monteith should:
- Verify coverage for Essure removal or Essure reversal using the above codes before surgery
- Pay for surgery in-full at the time of scheduling
- Submit a receipt for surgery payment and supporting billing documents with a Member Claim form to your health insurance company for reimbursement after your surgery has been completed.
- Request surgery reimbursement be mailed directly to you.
Health Insurance Reimbursement: Important points to understand
All patients must pay in full before having surgery with Dr. Monteith.
Your health insurance company should send your reimbursement for surgery directly to you after you have completed and submitted your Member Claim Form.
What is a Member Claim Form?
Every health insurance company has a Member Claim Form. You should be able to download the Member Claim Form directly from your health insurance company’s website.
After your surgery is completed, you will then need to submit the billing paperwork we provide you to your health insurance company for reimbursement.
We will provide you with more specific and comprehensive codes depending on the findings at the time of surgery. You will also be provided a receipt for surgery and diagnosis and procedure code sheet.
You will need to submit this information to your health insurance company using a “Member Claim form“.
We recommend you submit a Member Claim Form… even if they don’t cover the cost of surgery… because your health insurance company may apply the amount you paid for your surgery towards your yearly deductible. This means you may have to pay less for other health care expenses for the remainder of the year.
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.
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).