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    v1.0.28
    OpenPayerPolicy UpdatesReproductive Health & FertilityBlue Cross Blue Shield Michigan Sterilization Cove…
    Ask Trek AI about this page
    Currentblue cross blue shield - michiganPolicy N/A

    Sterilization (permanent contraceptive procedures) Coverage Criteria

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    This policy governs coverage, payment, and billing for sterilization procedures and related FDA‑approved contraceptive devices for BCN Advantage Medicare Advantage members; applicability depends on the member's certificate benefits and plan selections.

    Policy Summary
    Payerblue cross blue shield - michigan
    PolicySterilization (permanent contraceptive procedures) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeTemplate transitioncode updates noted
    Effective DateJan 1, 2026
    Next Review DateN/A
    Key ActionVerify member certificate benefits and obtain a prior coverage determination before providing services that may be noncovered.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    9+listed procedure codes
    NoneICD-10 restrictions
    Medicare-consistentpayment methodology
    Multipleeligible providers

    Coverage Criteria — Sterilization and Related Services

    Covered Sterilization Services

    Covered services when included in member certificate benefits and performed by eligible providers:

    General coverage requirements: Service is included in the member's certificate benefits AND performed by an eligible provider (M.D., D.O., physician assistant, nurse practitioner, registered nurse, clinical specialist) at a payable location (inpatient hospital, outpatient hospital, office).

    Frequency: no restrictions listed; CPT/HCPCS codes limited to listed codes

    Included procedures and products: FDA‑approved contraceptive drugs or devices prescribed by a qualified health care provider; vasectomy performed in the office setting; sterilization procedures in individuals with a uterus.

    Coverage applies only when included in the member's certificate benefits

    Coding and billing restrictions: Only the following CPT/HCPCS codes are applicable for payment: A4264, 55250, 58565, 58600, 58605, 58611, 58615, 58670, 58671, 58999.

    Diagnosis and age: no restrictions for payment

    Medicare Consistency and Enhancements

    Relationship to Medicare coverage:

    Medicare‑based coverage rule: BCN Advantage provides at least the same level of benefit coverage as Original Medicare and may provide enhanced benefits beyond Original Medicare within a single plan.

    Use Original Medicare as the base program when determining coverage

    Scope when Original Medicare is limited: Because Original Medicare offers limited coverage for elective sterilizations, the scope of the BCN Advantage sterilization benefit, reimbursement methodology, maximum allowable payment amounts and member cost sharing are determined by the BCN Advantage groups that select this benefit.

    Enhancements beyond Original Medicare depend on group selection

    The following items are excluded from coverage under this policy: contraceptive drugs or devices that are not FDA approved, and vasectomy procedures performed in an outpatient facility.

    These Medicare Advantage Enhanced Benefit Policies describe criteria BCBSM and BCN use to assess whether services are reasonable and necessary when Original Medicare guidance is limited; however, an Enhanced Benefit Policy is not an authorization, certification, explanation of benefits, or a contract. Enhanced benefit policies do not guarantee payment, do not constitute medical advice, and do not replace independent medical judgment.

    Coding — CPT, HCPCS, ICD-10, and Policy Code Changes

    CPT/HCPCS Codes (listed)mixed
    A4264Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
    55250Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)
    58565Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
    58600Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
    58605Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure)
    58611Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure)
    58615Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach
    58670Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
    58671Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, or Falope ring)
    58999Unlisted procedure, female genital system (nonobstetrical)
    ICD-10 DiagnosisICD-10
    ICD-10No restrictions — any diagnosis accepted for billing
    Policy history code changesCPT
    0567TRemoved (previous code)
    0568TRemoved (previous code)
    58999Replacement code effective 01/01/2025

    Provider Actions — Authorization, Documentation, and Billing

    Prior Authorization

    Coverage Dependent on Member Certificate

    Coverage is determined by the member's certificate benefits. Services not included on a member's certificate may be denied; noncovered services provided without a prior coverage determination may be denied.

    • Sterilization coverage is based on the member's certificate — verify benefits before providing services.
    • If the member elects to receive a noncovered service without a coverage determination, the member is responsible for charges but providers must hold the member harmless except for applicable cost share.
    Denial Risk

    Provider Responsibility and Denial Risk

    Providers must review applicable BCBSM/BCN reimbursement policies and the provider manual prior to claim submission. Failure to review and follow these policies may result in claim denials or requests for additional documentation.

    Background

    Sterilization refers to procedures intended to render an individual permanently incapable of reproducing by interrupting sperm transport (vasectomy) or preventing egg transit (tubal occlusion or salpingectomy). Procedures may be performed in office, via laparoscopy or mini‑laparotomy, or at the time of cesarean delivery; bilateral salpingectomy can also reduce ovarian cancer risk.

    Definitions

    Sterilization — definition and scope
    DefinitionAny medical procedure, treatment, or operation intended to render an individual permanently incapable of reproducing and not related to repair of a damaged or dysfunctional body part.
    IncludesVasectomy (interruption of the vas deferens) and tubal procedures (tubal occlusion, transection, removal of fallopian tubes).
    Procedural approachesOffice vasectomy; tubal occlusion or salpingectomy performed via laparoscopy, mini‑laparotomy, or at time of cesarean delivery.
    Clinical noteComplete removal of both fallopian tubes may also reduce ovarian cancer risk.
    ScopeCovers permanent contraceptive procedures intended to prevent pregnancy; not limited to treatment of injury or illness unless specified by payer benefits.
    Policy Summary
    Payerblue cross blue shield - michigan
    PolicySterilization (permanent contraceptive procedures) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeTemplate transitioncode updates noted
    Effective DateJan 1, 2026
    Next Review DateN/A
    Key ActionVerify member certificate benefits and obtain a prior coverage determination before providing services that may be noncovered.
    SourceLink
    On This Page
    Coverage Criteria — Sterilization and Related ServicesCoding — CPT, HCPCS, ICD-10, and Policy Code ChangesProvider Actions — Authorization, Documentation, and BillingBackgroundDefinitions
    • All providers are required to review BCBSM reimbursement policies before billing.
    • Contracted providers should also review the provider manual for additional claim submission requirements.
    • Non-contracted providers may be required to submit supporting documentation, including medical records, to substantiate billed services.
    Billing Rule

    Claim Documentation and Billing Requirements

    Report CPT/HCPCS and diagnosis codes to the highest level of specificity, include your NPI on all claims, and follow BCN Advantage billing instructions. Use electronic billing where available and submit claims on the appropriate claim form (CMS 1500, UB-04 or 837).

    • Report CPT/HCPCS and ICD-10 diagnosis codes to the highest specificity.
    • Include your National Provider Identifier (NPI) on all claims.
    • Bill on CMS 1500 (02/12), UB-04 or the 837 equivalent; follow BCN Advantage unique billing requirements.
    • BCN Advantage reimbursement follows Medicare allowed amounts; providers are paid the lesser of Medicare's allowed amount or the provider's charge, minus member cost share.
    • Send paper claims to BCN Advantage Claims, Blue Care Network, P.O. Box 68753, Grand Rapids, MI 49516-8753.
    Step Therapy

    Step Therapy

    No step therapy is specified for sterilization or contraceptive benefits in this policy.

    • If applicable for other services, follow any step therapy requirements listed in the member's benefit documents or prior authorization guidance.
    Prior Authorization

    Prior Authorization / Coverage Determination

    Prior coverage determination may be required for services that are noncovered or unclear under a member's certificate. Seek a coverage determination when coverage is uncertain to avoid unexpected member liability.

    • Obtain prior authorization/coverage determination for services not clearly covered by the member's certificate.
    • If there is any question about coverage, request a coverage determination from BCN Advantage before providing the service.
    • Providers may not have members sign an Advance Beneficiary Notice of Noncoverage to accept financial responsibility for noncovered items — seek prior coverage determination instead.