On January 10, 2022, the federal government released guidance ensuring access “to the full range of FDA-approved contraceptive methods including, but not limited to barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling, as prescribed
by a health care provider” without cost-sharing (deductibles or copays). This includes coverage of “sterilization surgery.” Previous guidance also
confirms that coverage includes “clinical services” that should also be covered
without co-pays or deductibles. Clinical services include office visits, tests, or procedures associated with birth control counseling, implantation, monitoring, and removal. This includes anesthesia and related pre-op
appointments.
Every preventive service has a unique
preventive service billing code that indicates to the insurance company that
the service is one they need to cover under the ACA’s requirement. A helpful
coding guide can be found here (relevant pages 23-25).
CPT-code 58661 (Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/ or salpingectomy)) and ICD-10 code Z30.2 (Encounter for sterilization are the appropriate codes for the bilateral salpingectomy) are the appropriate
codes for this procedure. We have seen many people have a bilateral salpingectomy coded this way (correctly) and still be denied by insurance. In these cases, insurance plans will claim that CPT code 58661 is not preventive, which is false. We have drafted a template appeal letter
specifically for this issue which I have attached. Please let me know if you want us to review your letter before you send it in; we are happy to help any way we can. If your insurance (or provider) is insisting that the code is diagnostic, it might be useful to share this information with your provider and make it clear that because the purpose of the surgery is sterilization, you
insurance should be covering it without cost sharing. There is also an option
for your provider or the billing office to attach Modifier 33 to the CPT code. This modifier indicates that the services are preventive, even if the procedure does not have a unique preventive service code. Information about Modifier 33 can be found on page 5 of the coding guide linked above.
If you do find that your insurance should be
covering your bilateral salpingectomy but is not, or you get the run around about getting your surgery or related services covered, you can file a written appeal with your health insurance plan. Appealing your plan’s coverage might
prompt changes for you and other women in the plan, and a successful appeal may result in coverage or a refund for money you’ve paid out of pocket for birth control. The links below includes information and a sample appeal letter specific to billing code issues for bilateral salpingectomies, which should be helpful for you. I would check out both the letters to see which one you think makes the most
sense for your situation.
Medical management issue:Another issue to be aware of is that plans are allowed to practice “reasonable medical management” within each of the 18 FDA-approved contraceptive methods. This means they can cover one type of surgery but not another, such as choosing to cover tubal ligation and not bilateral salpingectomy.
However, if your plan is practicing medical management here, there should still be a way to get coverage of your prescribed surgery through what is called the “waiver” or “exceptions” process. In this situation insurance companies must provide “an easily accessible, transparent,
and sufficiently expedient exceptions process that is not unduly burdensome on
the individual or a provider” to get no-cost-share coverage of any service or
FDA-approved item within the specified method of contraception. If an individual’s provider recommends a particular service or FDA-approved item based on a determination of medical necessity with respect to that individual, the plan must cover that service or item without cost-sharing. The waiver process may be different for each plan, but you or your health care provider should be able to call your plan to get more information or get the process started. We also have specific language for appeal letter if your plan does not have a waiver process in place (many plans don’t, and it’s a violation of the ACA) please reach out for a copy of that template letter if you need it.