Highmark Medicare Advantage Medical Policy in West Virginia

Section:	CMS National Guidelines
Number:	N-168
Topic:	Sterilization - NCD 230.3
Effective Date:	May 25, 2009
Issued Date:	May 25, 2009

General Policy

Sterilization services are eligible only if it is a necessary part of the treatment of an illness or injury.

Indications and Limitations of Coverage

Payment may be made only where sterilization is a necessary part of the treatment of an illness or injury, e.g., removal of a uterus because of a tumor, removal of diseased ovaries (bilateral oophorectomy), or bilateral orchidectomy in a case of cancer of the prostate. Claims will be denied when the pathological evidence of the necessity to perform any such procedures to treat an illness or injury is absent; and
Sterilization of a mentally retarded person is covered if it is a necessary part of the treatment of an illness or injury.

Medical record documentation may be requested to determine if the surgery was performed as a means of treating an illness or injury or only to achieve sterilization.

Reasons for Noncoverage

Elective hysterectomy, tubal ligation, and vasectomy, if the stated reason for these procedures is sterilization;
A sterilization that is performed because a physician believes another pregnancy would endanger the overall general health of the woman is not considered to be reasonable and necessary for the diagnosis or treatment of illness or injury. The same conclusion would apply where the sterilization is performed only as a measure to prevent the possible development of, or effect on, a mental condition should the individual become pregnant; and
Sterilization of a mentally retarded person where the purpose is to prevent conception, rather than the treatment of an illness or injury.

Services performed for elective sterilization (V25.2) are not a covered service. A provider can bill the member for the denied service.

NOTE:: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

55250	55450	58600	58605	58611	58615
58670	58671

Coding Guidelines

Publications

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual System Pub. 100-3, Chapter 1, Section 230.3

www.cms.gov

www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

V25.2

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.