| Effective Date:09/18/1995 |
Title:Sterilization
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| Revision Date:01/01/2018
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Document:BI065:00
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| CPT Code(s):55250, 58600-58615, 58670-58671, 58700
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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.
Elective Sterilization is a covered service. Any
hospital confinement solely for sterilization requires pre-authorization;
outpatient procedures do not. BI059 Reversal of Sterilization procedure is not
covered.
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Medical Statement
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1)
Elective Sterilization is a covered service. Any hospital confinement
solely for sterilization requires pre-authorization; outpatient procedures do
not.
2)
BI059 Reversal of Sterilization procedure is not covered.
3)
For coverage considerations regarding the Essure Device, see BI372.
Codes
Used In This BI:
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55250 |
Removal of sperm duct(s) |
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58600 |
Division of fallopian tube |
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58605 |
Division of fallopian tube |
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58611 |
Ligate oviduct(s) add-on |
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58615 |
Occlude fallopian tube(s) |
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58670 |
Laparoscopy tubal cautery |
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58671 |
Laparoscopy tubal block |
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58700 |
Removal of fallopian tube |
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Limits
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QualChoice reviews and authorizes services and substances. Billing and procedure
codes change from time to time and QualChoice medical policies may not always
reference the current published codes. This does not change the intent or effect
of the policy language, nor does it affect the necessity for appropriate
process. The codes are included in Medical Policies as a convenience to the
readers of the policy.
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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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