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Will Health Insurance Pay For Tubal Reversal Surgery?

Almost everyone considering tubal reversal will ask “Will health insurance pay for tubal reversal surgery?

will-health-insurance-pay-for-tubal-reversal-surgeryUnderstandably, 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

Screening laparoscopy
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

Vasectomy Reversal
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!

Health-insurance-typically-does-not-pay-for-tubal-reversal-surgeryIf 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.

What if health insurance will not cover tubal reversal surgery?

If you discover your health insurance company will not pay for reversal then do not be too surprised. Most health insurance companies will not cover tubal ligation reversal because they consider it an elective surgery for a non-threatening medical condition.

health-insurance-will-not-cover-tubal-reversal-even-if-you-have-PTLS-symptomsGetting breast implants, face lifts, tummy tucks or liposuction are cosmetic procedures that a person does to make themselves look or feel better. These are elective surgeries and health insurance plans do not cover procedures they deem as not medically necessary.

Unfortunately most health insurance plans treat tubal ligation reversal surgery just like cosmetic surgery… something you do because you ‘want to’ and not necessarily because you ‘need to’. They basically are saying, ” We paid you to get it done…now we are not also going to pay for you to get it undone!”

Health insurance plans do not care if you report symptoms after your tuba ligation. The main reason they do not care is because when patients discover the surgery is not covered they then claim side effects from the initial procedure. Health insurance companies are aware of this tactic and they refuse to recognize that you may be having symptoms as a result of your tubal ligation.

If your health insurance will not pay for reversal then you should consider financing your reversal surgery.

Financing tubal reversal surgery

If your health insurance will not pay for reversal then you can consider financing tubal reversal surgery.

Many patients will finance their surgery because this can provide you with the ability to have surgery now and pay later.

More information: Financing tubal reversal surgery

A Personal Choice works with leaders in the field of health care financing. They currently work with CareCredit and United Medical Credit. These two companies are giants in the field of health care financing. They can provide many patients with the financial means to make your dreams of having reversal surgery a reality.

Have Questions? We’re Happy To Help!

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Your questions about reversal surgery will be answered directly and promptly by Dr. Monteith. Please read our most frequently asked questions before submitting your questions. Dr. Monteith will not respond to general medical questions or if you are a patient of another doctor and are contacting him because your doctor is unavailable.* If you have been a patient at our reversal center and have specific questions about your medical care you should contact the reversal staff directly at (919) 977-5050.

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If you are considering reversal surgery and have questions about the procedure, fill in the form below and we'll get back to you as soon as we can! If you would like to speak with a nurse for a Free Consultation then feel free to call us at (919) 977-5050.

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