A tubal reversal or tubal ligation is a procedure that surgically corrects and reconstructs the fallopian tubes of the female reproductive system for purpose of conceiving. The procedure is performed by a credentialed surgeon who is considered an accomplished specialist in his or her field with proficiency to restore functional capacity of fertility. There are basically three standard operations utilized in the medical community to accomplish this reconstruction which are displayed prominently in media including implantation, anastomosis, and a salpingostomy. All variations of correcting the problem are operationally invasive, inherent in risk, relatively expensive, and elective thus not usually covered under normal circumstance by health insurance, or is it?
Why Is Tubal Reversal Usually Or Normally Not Covered By Insurance?
A medically underwritten plan for an individual would require an exclusionary benefit period for a prolonged duration of time while reinvesting the monthly premium at regular intervals to earn sufficient return on invested capital hence funding the operation. The median average claim expenditure for Tubal Reversal Ligation surgery can run anywhere from $4,500.00 to $10,000.00 depending on several factors such as history of female complications, age, height, or weight and with just one person to pool this risk the cost of covering exceeds the insurers return on investment by a wide margin. The second reason is the fact that very speculative complications can occur during the course of operating such as excessive bleeding, infection, anesthetic casualty, damage to nearby organs, and risk of ectopic pregnancy all which would only exacerbate the claim cost expenditures and cause negative asymmetries in the medical loss ratio costing a fortune for the insurance company.
Exceptions To The Rule.
Group insurance benefits are unsurpassed in the arena of coverage and most often commercial insurance carriers write experienced rated policies instead of medically underwritten benefits to cover these procedures which are offset by factoring the premiums of the business enterprise as a whole. Simply put, with many employees paying monthly premiums there is financial leverage to provide this as a covered expense. Some states are required by federal mandated law to honor payment for Tubal Reversal Ligation if they do in fact cover maternity regardless of the provisions stipulated within its contractual arrangements with the insured. As a matter of fact, The National Infertility Association has addressed them by state including Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, West Virginia, and Texas. The caveat is there are certain loopholes in regards to evading or meeting such requirements such as not all carriers being required to offer maternity related coverage’s.
Applying for Tubal Reversal Insurance.
Our company Health Insurance Buyer will assist you in locating such coverage from carriers like Blue Cross Blue Shield, Humana, and Aetna to name a few insurance companies as well as help you locate reputable providers that perform the aforementioned services such as Chapel Hill Tubal Reversal Center, Center for Fertility and Gynecology, or Atchafalaya Obstetrics and Gynecology as an example. Once our health insurance agency has identified a carrier for you in your respective geographical area which provides coverage for these special infertility treatments and helps you apply for these benefits, there are some steps you need to take. We will need to make sure you request and obtain your operative notes and pathology report from the original physician or hospital where the sterilization was performed validated by date of service. Also needed are birth date, current address, height, weight, and maiden name along with any other names or information that may have been used at the time. Recent evaluation for testing of Pap smear, Cervical Culture, Blood Count, and Obstetrical Panel will have to be up to date for clearance. Last but not least, upon remitted claim submittal special attention has to be made to make sure the International Classification of Diseases (ICD-9) diagnosis code for bilateral tubal occlusion is billed as 628.2 and Current Procedural Terminology (CPT) procedure code for tubal anastomosis is billed accordingly as 58750 for maximum allowable reimbursement.