Will Health Insurance Pay For Tubal Reversal Surgery?
Almost everyone considering tubal reversal will ask “Will health insurance pay for tubal reversal surgery?”
Understandably, tubal reversal and vasectomy reversal are not cheap. Both are surgeries and it is natural to wonder if health insurance will pay for all…or at least some…of the cost of reversal surgery.
Although some health insurance companies may cover part of the cost of reversal surgery, most health insurance companies consider reversal surgery an elective surgery and will not pay for reversal surgery.
Even if your health insurance does not pay for the entire cost of reversal surgery, we will provide you with tips that may help you get some financial benefit.
Preverification: Will health insurance pay for your reversal surgery?
Your health insurance is a contract between you and your health insurance company. You pay them every month and, in return, they agree to cover your necessary medical expenses. Very often what they will cover is detailed in the contract you signed when you began your coverage with the health insurance company.
Health insurance companies are reluctant to cover anything that is not medically necessary. This is why most cosmetic and plastic surgery procedures are not covered.
Unfortunately, most health insurance companies consider infertility treatment or infertility surgery to be non-life-threatening conditions that do not require medical necessary treatments/procedures.
The best way to determine if your health insurance company will pay for your reversal surgery is to call your health insurance company and ask if they will cover your procedure. This is called preverification.
Preverification: Use these medical codes
They will ask you for both the ICD-10 diagnosis code and the CPT surgical procedure code before they can determine if the procedure is covered. Below are the ICD-10 and CPT codes for our tubal surgery procedures.
Tubal ligation reversal
The following codes are tubal reversal codes for patients who want reversal of their tubal ligations.
- ICD-10 code for bilateral tubal occlusion is N97.1
- CPT code for tubal reversal is 58750
This following codes are only for patients who will be having the optional screening laparoscopy procedure during their tubal reversal surgery. Your health insurance representative will need the both the codes shown below and the tubal reversal codes shown above.
- ICD-10 code for bilateral tubal occlusion is N97.1
- CPT code for screening laparoscopy 49320
The following codes are codes for patients who want reversal of their vasectomy.
- ICD-10 code for bilateral occlusion of vas deferens N50.8 and reversal of vasectomy sterilization Z31.0
- CPT code for vasectomy reversal surgery 55400
If you have contacted your health insurance company and they have agreed to pay for all or part of your surgery then great!
Most health insurance companies will not pay for tubal reversal or vasectomy reversal surgery…. so don’t get your hopes too high.
Preverification: Will you need a letter proving medical necessity?
Sometimes your health insurance company will say they will pay for tubal reversal surgery but only if a doctor provides a letter of medical necessity.
A letter of medical necessity is a letter provided by your local doctor describing what your symptoms are, what your diagnosis is, and why a reversal surgery is medically required. This is sometimes requested when patients report the reason for the reversal is for abnormal symptoms or Post Tubal Ligation Syndrome.
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 accept payments from health insurance carriers or 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 such a letter either before or after reversal surgery.
Your primary care doctor…or the doctor evaluating you for symptoms after tubal ligation…. will have to provide the letter documenting your symptoms and explaining the medical necessity of your surgery.
Getting Reimbursement Reversal Surgery: Submit Member Claim Form
If you were told you would be covered for reversal surgery then you have a great health insurance plan. Congratulations!
If you are having reversal surgery at A Personal Choice you will have to pay for the full cost of reversal surgery at the time of scheduling. We are unable to bill your health insurance company before or after surgery.
After your surgery is completed, you will then need to submit the billing paperwork 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“.
You should be able to download the Member Claim Form from your health insurance company’s website.
Health Insurance and tubal reversal: Advice on obtaining reimbursement
If your health insurance carrier will cover part of or all of the cost of your surgery, you will need to submit a Member Claim Form after surgery is completed.
Include the documents we provide you. Make sure they send the reimbursement check to you directly.
It is important to submit a Member Claim Form… even if they don’t cover the cost of reversal surgery… because they may apply the amount you paid for your reversal surgery towards your yearly deductible. This means you may have to pay less for other health care expenses for the remainder of the year.