Coverage Policies

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If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 08/01/2012 Title: Women`s Preventive Health Care - Contraception
Revision Date: 11/01/2020 Document: BI372:00
CPT Code(s): A4261, A4264, A4266, J1050, J2675, J7296-J7297, J7298, J7300, J7301, J7303, J7304, J7306, J7307, S4981, S4989, S4993, 00840, 00851, 11976, 11980, 11981, 11982, 11983, 57170, 58300, 58301, 58340, 58565, 58600, 58605, 58611, 58615, 58661, 58670, 58671, 74740, 76857, 96372, 99201, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99384, 99385, 99386, 99394, 99395, 99396
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.

A.   General provisions:

1.    Some QualChoice administered plans do not cover contraceptive techniques. Others may have restricted coverage for contraception, limited to certain techniques.  This could be the case, for example, if your employer group is a religious organization.  You should check your coverage document to verify coverage under your plan.

2.    Beginning on your plan’s first renewal date with QualChoice on or after August 1, 2012, coverage for certain birth control measures will be provided without member cost share as more fully described below.

3.    In order for the benefits described in this policy to apply to you, your plan must be a non-grandfathered health plan or a grandfathered plan being administered by QualChoice as a non-grandfathered plan.

4.    Consult your plan documents by logging into www.qualchoice.com and select Benefit Booklet.

B.   The following medical services are covered without member cost share:

1.    Removal of long acting contraception, such as Implanon

2.    Tubal ligations and associated services; this includes salpingectomy or use of tubal occlusion devices, such as Essure. 

3.    Insertion or implantation of birth control pellets and capsules.

4.    Fitting and insertion of diaphragms, rings and caps.

5.    Injection of long acting contraceptives.

C.   The following prescription birth control methods and devices are covered without member cost share:

1.    All oral contraceptives in either formulary Tiers 1 or 2.

2.    Xulane patch

3.    Generic Nuvaring (brand name Nuvaring not covered)

4.    Generic medroxyprogesterone acetate injection

5.    Caps and diaphragms

6.    Emergency contraceptives (e.g. Plan B, Ella)

D. The following services and prescriptions are not covered:

1.    Abortion or abortifacient drugs

2.    Reversal of permanent contraceptive procedures, for example, reversal of tubal ligation

3.    Birth control methods that are available without a prescription

E.   The following services are covered under the standard medical benefit:

1.    Vasectomies

2.    Additional procedures are not covered without cost share.  For example, if a tubal ligation is performed at the same time as delivery of a baby, only the specific tubal procedure is covered without cost share.

F.    Out-of-network services and prescription birth control methods and devices may be non-covered or subject to cost-share. Consult your plan documents.

For other preventive care services, please see BI062.


Medical Statement

A.   Some QualChoice administered plans do not cover contraceptive techniques. Others may have restricted coverage for contraception, limited to certain techniques.  This could be the case, for example, if the employer group is a religious organization.

B.   For plans that cover contraception without member cost share, the following provisions apply:

1.     The following codes are covered without member cost share when used with the appropriate/corresponding ICD-10 Diagnosis codes:

a)     A4261 – Cervical cap for contraceptive use

b)     A4264 – Permanent implantable intratubal occlusion device

c)     A4266 – Diaphragm contraceptive

d)     J1050 – Medroxyprogesterone Acetate Inj, 1 mg

e)     J2675 – Progesterone Inj, 50 mg

f)      J7297 – Levonorgestrel IUD, 3 yr (Liletta)

g)     J7298 – Levonorgestrel IUD, 5 yr (Mirena)

h)     J7300 – Copper IUD

i)      J7301 – Skyla IUD

j)      J7303 – Hormone containing vaginal ring contraceptive

k)     J7304 – Hormone containing patch contraceptive

l)      J7306 – Levonorgestrel implant system

m)   J7307 – Etonogestrel implant system

n)     J7296 – Kyleena IUD

o)     S4981 – Insertion of progesterone containing IUD

p)     S4989 – Progestasert IUD, or other IUD

q)     S4993 – Birth control pills

r)      00840 – Anesthesia for intraperitoneal proc in lower abdomen incl laparoscopy; NOS

s)     00851 – Anesthesia for intraperitoneal proc in lower abdomen incl laparoscopy; tubal

               ligation/transection

t)      11976 – Removal implantable contraceptive capsules (only with 11981)

u)     11980 – Subcutaneous hormone pellet implantation

v)     11981 – Insertion, non-biodegradable drug delivery implant

w)    11982 – Removal, non-biodegradable drug delivery implant (with Z30.46)

x)     11983 – Removal & reinsertion, non-biodegradable drug delivery implant

y)     57170 – Fitting of diaphragm

z)     58300 – Insertion of IUD

aa)  58301 – Removal of IUD

bb)  58340 – Catheterization and introduction of saline or contrast material for saline infusion

               sonohysterography (SIS) or hysterosalpingography is covered one time when

                               performed within 120 days of 58565 (same DOS as 58300).

cc)  58565 – Hysteroscopy and tubal ablation

dd)  58600 – Ligation/transection of fallopian tube(s), abd or vag approach, unilat or bilat

ee)  58605 – Ligation/transection of fallopian tube(s), abd or vag approach, postpartum, unilat

               or bilat, during same hospitalization (sep procedure)

ff)     58611 – Ligation/transection of fallopian tubes at time of Cesarean delivery or intra-abd

               surgery (not a separate procedure—listed in addition to primary procedure)

gg)  58615 – Occlusion of fallopian tube(s) by device vaginal or suprapubic approach

hh)  58661 – Laparoscopic salpingectomy

ii)     58670 – Surgical laparoscopy w/fulguration of oviducts (+/- transection)

jj)     58671 – Surgical laparoscopy; w/occlusion of oviducts by device

kk)  74740 –  Hysterosalpingography, radiological supervision and interpretation is covered one

                time when performed within 120 days of 58565

ll)    76857 –  Pelvic Ultrasound

mm)         96372 –  Therapeutic, prophylactic or diagnostic injection

nn)  99202 – 99205 – New patient office visit (code 99201 replaced by 99202 eff 01-01-2021)

oo)  99212 – 99215 – Established patient office visit

pp)  99384 – 99386 – New patient preventive care visit, age 12 – 64

qq)  99394 – 99396 – Established patient preventive care visit, age 12 - 64

2. The following codes are covered under the standard medical benefit:

a)    58301 – Removal of IUD (unless followed by 58300)

b)    11976 – Removal of implantable contraceptive capsules (unless followed by 11981)

c)    11982 – Removal, non-biodegradable drug delivery implant

3.    Prescriptions for birth control items will be covered without member cost share based on the  

     following criteria, otherwise will be covered under the standard prescription benefit:

a)    All oral contraceptives in tiers 1 and 2 in the formulary

b)    Ortho Evra patch

c)    Generic medroxyprogesterone acetate injection.

d)    Nuvaring

e)    Emergency contraceptives (e.g. Plan B, Ella).

4.    Condoms are not covered.

5.    Vasectomies are covered under the standard medical benefit.

6.    Tubal ligations and tubal occlusions are covered without cost share.

a)    Additional procedures are not covered without cost share.  For example, if a tubal ligation is performed at the same time as delivery of a baby, only the specific tubal procedure is covered without cost share.

Codes Used In This BI:

A4261

Cervical cap for contraceptive use

A4264

Permanent implantable intratubal occlusion device

J1050

Medroxyprogesterone Acetate Inj, 1 mg

J2675

Progesterone Inj, per 50 mg

J7296

Kyleena IUD (new 1/1/18)

J7297

Levonorgestrel IUD, 3 yr (Liletta)

J7298 

Levonorgestrel IUD, 5 yr (Mirena)

J7300 

Copper IUD

J7301 

Skyla IUD

J7302 

Mirena IUD (deleted 1/1/16)

J7303 

Hormone containing vaginal ring contraceptive

J7304 

Hormone containing patch contraceptive

J7306 

Levonorgestrel implant system

J7307 

Etonogestrel implant system

Q9984

Kyleena IUD (deleted 1/1/18)

S4981

Insertion of progesterone containing IUD

S4989

Progestasert IUD, or other IUD

S4993

Birth control pills

00840

Anesthesia for lower abdominal procedure NOS

00851

Anesthesia for tubal ligation

11976

Removal implantable contraceptive capsules

11980

Subcutaneous hormone pellet implantation

11981

Insertion, non-biodegradable drug delivery implant

11982

Removal, drug delivery implant

11983

Removal & reinsertion, drug delivery implant

57170

Fitting of diaphragm

58300

Insertion, IUD

58301

Removal of IUD

58340

Catheterization & intro of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography

58565

Hysteroscopy and tubal ablation

58600

Ligation of fallopian tubes

58605

Ligation of fallopian tubes

58611

Ligate/transect fallopian tubes at time of Cesarean section or intra-abd surgery

58615

Occlusion of fallopian tube(s) by device vaginal or suprapubic approach

58661

Laparoscopic salpingectomy

58670

Laparoscopic fulguration of fallopian tubes +/- transection

58671

Laparoscopic occlusion of fallopian tubes by device

74740

Hysterosalpingography, radiological supervision & interpretation

76857

Pelvic Ultrasound

96372

Therapeutic, prophylactic or diagnostic injection

99202 - 99205

New patient office visit (code 99201 deleted and replaced by 99202 eff 01-01-2021)

99212 - 99215

Established patient office visit

99384 - 99386

New patient preventive care visit, age 12 – 64

99394 - 99396

Established patient preventive care visit, age 12 - 64


Reference

Addendum:

1.    Effective 08/01/2017: Added new Kyleena IUD HCPCS code and codes for additional sterilization techniques as well as need for corresponding ICD-10 diagnosis codes to determine payment under preventive or medical benefit.

2.    Effective 01/01/2018: Hysterosalpingography (58340 and 74740) is covered once when performed 90 to 120 days after hysteroscopic tubal obliteration procedure (58565).

3.    Effective 1/1/2018: 2018 Code Updates. Updated Claim Statement section & Codes Used in This BI section to reflect new/deleted CPT/HCPCS codes. The following code was deleted 1/1/18: Q9984. This code was replaced with the following new code effective 1/1/18: J7296.

4.    Effective 4/1/2020: Laparoscopic salpingectomy (58661) covered as preventive for sterilization.

5.    Effective 01/01/2020: Removal of contraceptive devices is covered without member cost share.

6.    Effective 01-01-2021: Deleted code 99201 and replaced by 99202.  Separated code ranges in the search box to make all codes searchable.


Application to Products

This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, 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.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.