| Effective Date:07/28/2004 |
Title:Reversal of Sterilization
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| Revision Date:
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Document:BI059:00
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| CPT Code(s):55400, 58750 , 58752, 58760, 58770
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Public Statement
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Effective Date:
a)
This policy
will apply to all services performed on or after the above revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
Sterilization
reversal techniques are not covered.
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Medical Statement
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Sterilization reversal techniques are not covered Refer to contract for specific exceptions. Codes Used In This BI: 55400 Vasovasostomy (reversal of vasectomy) 58750 Tubotubal anastomosis (reversal of tubal ligation) 58752 Tubo-uterine implantation (reversal of tubal ligation) 58760 Fimbrioplasty (repair of fallopian tube end) 58770 Salpingostomy (opening of fallopian tube)
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Limits
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Intentially left empty
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Reference
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Intentially left empty
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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