Medical Policy

Effective Date:07/28/2004 Title:Reversal of Sterilization
Revision Date: Document:BI059:00
CPT Code(s):55400, 58750 , 58752, 58760, 58770
Public Statement

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.
Medical Statement

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)

Intentially left empty
Intentially left empty
Application to Products
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.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.