Local Coverage Article

Sterilization

A52960

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Contractor Information

Article Information

General Information

Article ID
A52960
Original ICD-9 Article ID
A50624
Article Title
Sterilization
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
04/12/2018
Revision Ending Date
N/A
Retirement Date
N/A
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Article Guidance

Article Text
Sterilization means any medical procedure, treatment or operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged/dysfunctional body part.

Under the Medicare Program guidelines the coverage of sterilization is limited to necessary treatment of an illness or injury. An example of necessary treatment is the removal of a uterus or removal of diseased ovaries (bilateral oophorectomy) because of a tumor, or bilateral orchiectomy in the case of prostate cancer.

Elective hysterectomy, tubal ligation and vasectomy in the absence of a disease for which sterilization is considered an effective treatment is not covered. In addition, no payment would be made for sterilization procedures if it is a preventive measure e.g., a physician believes pregnancy would cause overall endangerment to a woman's health, or as a measure to prevent the possible development of, or effect on a mental condition, should pregnancy occur. (Section 1862(a)(1)(A) of the Social Security Act and 42 CFR 411.15(k).

Claims will be denied on postpay review and payment recouped if the pathological evidence of the necessity to perform any of these procedures to treat an illness or injury is absent and/or when the primary objective is to achieve sterilization.



Coding Information

CPT/HCPCS Codes

Group 1

(7 Codes)
Group 1 Paragraph

The following procedures, when used for sterilization to prevent reproduction, will be auto-denied due to the absence of a Medicare benefit category.


Group 1 Codes
CodeDescription
55250 VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)
58600 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, UNILATERAL OR BILATERAL
58605 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, POSTPARTUM, UNILATERAL OR BILATERAL, DURING SAME HOSPITALIZATION (SEPARATE PROCEDURE)
58611 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT THE TIME OF CESAREAN DELIVERY OR INTRA-ABDOMINAL SURGERY (NOT A SEPARATE PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
58615 OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG, BAND, CLIP, FALOPE RING) VAGINAL OR SUPRAPUBIC APPROACH
58670 LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)
58671 LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE (EG, BAND, CLIP, OR FALOPE RING)

ICD-10-CM Codes that Support Medical Necessity

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

ICD-10-CM code Z30.2, sterilization should be noted in Item 24E of the CMS-1500 claim form or the electronic equivalent:

Group 1 Codes
CodeDescription
Z30.2 Encounter for sterilization

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
04/12/2018 R4

Article converted to Billing and Coding, no other changes were made

04/12/2018 R3

This article effective 4/12/2018, combines JEA A54071 in JEB A54072 so that both JEA and JEB Contract numbers will have the same final MCD Article number A54072.

04/12/2018 R2

This Article effective 4/12/2018 combines JFA A53354 in to JFB A52960 so that both JFA and JFB contractor numbers will have the same final Medicare Coverage Database Article Number, A52960.

10/01/2015 R1 This article is republished to remove information specific to Jurisdiction F and is being published in Jurisdiction E also.

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
N/A
Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
09/29/2020 04/12/2018 - N/A Currently in Effect You are here
04/02/2018 04/12/2018 - N/A Superseded View
04/02/2018 04/12/2018 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Sterilization
  • Vasectomy
  • Tubal
  • Ligation
  • Vaginal
  • Fallopian
  • Oviduct
  • hysterectomy
  • 55250
  • 58600
  • 58605
  • 58611
  • 58615
  • 58670
  • 58671