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    v1.0.31
    OpenPayerPolicy UpdatesObstetrics/GynecologyCurative Contraceptive Surgery Coverage | OpenPaye…
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    CurrentCurativePolicy CHP-OP-2026-034

    34. Surgery - Contraceptive

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    This policy governs coverage and clinical review for female sterilization, IUD insertion, removal, or replacement, bilateral salpingectomy when performed for contraception, and vasectomy when included in the member's benefit. It applies to all ages unless a specific federal or state consent rule applies to the funding source, and evaluates the elected method, consent, documentation, and applicable benefit rules.

    Policy Summary
    PayerCurative
    Policy34. Surgery - Contraceptive
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateNovember 5, 2026
    Next Review DateN/A
    Key ActionDocument the requested contraceptive method or procedure and the member's election.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    7Female sterilization procedure codes listed
    1Vasectomy procedure code listed
    30–180 daysFederal consent waiting period
    No limitIUD insertion or removal
    No minimum ageCommercial coverage conditions

    Coverage Criteria

    Female sterilization

    Covered without cost sharing and approved when ALL of the following are documented.

    • Permanent contraception method: The member requests permanent contraception and the procedure is a female sterilization method, including tubal ligation or occlusion by any route, or bilateral salpingectomy for sterilization.

      Includes procedures performed at cesarean delivery or immediately postpartum.

    • Informed consent is documented. When the federal sterilization consent rule applies because the procedure is supported by federal program funding, the federal consent form, age requirement, and waiting period are met; otherwise, standard surgical informed consent is sufficient.Federal rule: age 21 or older and 30–180 days between consent and sterilization, subject to the 72-hour exception when applicable.

      Commercial plan coverage alone does not trigger the federal consent rule.

    Policy Summary
    PayerCurative
    Policy34. Surgery - Contraceptive
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateNovember 5, 2026
    Next Review DateN/A
    Key ActionDocument the requested contraceptive method or procedure and the member's election.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Federal Consent RequirementsProvider Documentation and Review ActionsPolicy BackgroundDefinitions
    Safety planning:
    Any surgical or anesthetic contraindication has a documented management plan, such as the planned route, setting, or anesthesia approach.

    IUD insertion, removal, or replacement

    Covered without cost sharing and approved when ALL of the following are documented.

    Eligible IUD

    • FDA-approved or cleared device: The device is an FDA-approved, granted, or cleared intrauterine contraceptive, including copper or progestin devices of any duration and dose, or the service is removal or replacement of such a device.
    • Member election and clinical appropriateness: The member has elected the method; insertion may occur at any time, including immediately postpartum or after abortion, when the clinician determines it is appropriate.
    • Medical-management exception process: When a plan applies medical management within the IUD category, the attending provider's determination that a specific product is medically necessary is honored through the exceptions process.

      The exceptions process must be accessible, transparent, and sufficiently expedient.

    Contraceptive method used to treat a medical condition

    Review according to the indication and the member's contraceptive election.

    Applicable indication pathway

    • Hormonal IUD for a medical condition

      • A hormonal IUD placed to treat heavy menstrual bleeding, endometrial hyperplasia, or to provide endometrial protection is approved for that indication as well as on the member's contraceptive election.

        Documentation of the indication is not required when the member also elects the method for contraception.

    • Salpingectomy for a gynecologic condition

      • Salpingectomy performed for a gynecologic condition such as hydrosalpinx or ectopic pregnancy is reviewed under Policy 35.

        Opportunistic salpingectomy during another pelvic surgery is supported and does not change review of the primary procedure.

    Vasectomy

    Where the plan benefit covers vasectomy, approve when ALL of the following are documented.

    Benefit eligibility and election

    • Permanent contraception request: The member requests permanent contraception.
    • Benefit or mandate coverage: The plan benefit or a state mandate that applies to the member's plan covers male sterilization.

      Applicable plan types include fully insured plans and self-funded plans whose plan document adopts the mandate. Vasectomy is not included in the federal women's preventive mandate.

    • Informed consent is documented, and the federal consent rule is met when it applies because of the funding source.
    • Cost-sharing treatment: Cost sharing follows the plan benefit and any applicable state mandate.In an HSA-qualified high-deductible plan, the deductible applies unless federal guidance changes.

    Continuation, repeat service, and re-authorization

    Follow-up contraceptive services are covered on the same basis when ANY of the following applies.

    Continuation, repeat service, or re-authorization

    • IUD follow-up: Removal, replacement, or repositioning of an IUD is requested or clinically performed at any time and for any reason, including at the member's request.
    • Sterilization follow-up: Follow-up care after sterilization, including management of procedure complications, is needed.
    • Repeat sterilization after documented failure: A second sterilization procedure follows documented failure of a prior sterilization.Documented failure means confirmed pregnancy or imaging showing tubal patency.

    Sterilization reversal, including tubal reanastomosis and vasovasostomy, is outside this policy. These services are adjudicated under the member’s plan benefit and Policy 109, including any applicable plan exclusions.

    New hysteroscopic sterilization using a micro-insert device is not supported. No FDA-approved hysteroscopic sterilization device has been marketed in the United States since December 31, 2018; therefore, this policy does not support new procedures using that approach.

    Federally funded sterilization that lacks the required federal consent form, age requirement, or waiting period does not satisfy the federal consent requirement when no applicable exception applies. The request must undergo physician and compliance review rather than being processed as meeting criteria.

    Requests that do not meet the stated criteria must be referred for physician review. They may not be denied by an automated system or non-physician reviewer; an adverse determination may be issued only by a licensed physician of the same or similar specialty after an opportunity for peer-to-peer discussion.

    Coding and Federal Consent Requirements

    Intrauterine contraceptive devices and insertionHCPCS
    S4981Intrauterine contraceptive devices and insertion (HCPCS S codes)
    S4989Intrauterine contraceptive devices and insertion (HCPCS S codes)
    IUD insertion and removal proceduresCPT
    58300IUD insertion and removal procedures
    58301IUD insertion and removal procedures
    Female sterilization proceduresCPT
    58565Female sterilization procedures; retained for legacy claims only
    58600Female sterilization procedures
    58605Female sterilization procedures
    58611Female sterilization procedures
    58615Female sterilization procedures
    58670Female sterilization procedures
    58671Female sterilization procedures
    VasectomyCPT
    55250Vasectomy
    Bilateral salpingectomy reported with an adnexal procedure codeCPT
    58661Example adnexal procedure code used to report bilateral salpingectomy when the purpose is contraception
    Federal sterilization consent waiting period
    Applies whenThe federal sterilization consent rule applies to sterilizations supported by federal program funding; commercial plan coverage alone does not trigger it.
    Minimum intervalAt least 30 days must elapse between consent and sterilization.
    Maximum intervalSterilization must occur not more than 180 days after consent.
    Federal consent exception
    Exception periodA 72-hour exception may apply to the federal sterilization consent waiting period.
    Premature deliveryThe exception applies when sterilization occurs in connection with premature delivery.
    Emergency abdominal surgeryThe exception also applies in connection with emergency abdominal surgery.

    Provider Documentation and Review Actions

    Documentation Required

    Member Election

    Document the contraceptive method or procedure requested and the member’s election.

    • Contraceptive method or procedure requested
    • Member’s election
    Documentation Required

    Consent Documentation

    Document informed consent and, when the federal consent rule applies, the signed federal consent form with dates showing waiting-period compliance or the applicable exception.

    • Signed federal consent form when applicable
    • Dates demonstrating compliance with the waiting period or the exception used
    Documentation Required

    Planned Procedure and Approach

    Document the planned procedure and approach, including the relevant delivery or device details.

    • Laparoscopic approach
    • Sterilization at cesarean delivery or postpartum
    • IUD type
    Documentation Required

    Contraindication Management

    Provide a management plan for any surgical or anesthetic contraindication before the service proceeds.

    • Identify the contraindication
    • Document the surgical or anesthetic management plan
    Documentation Required

    Non-Contraceptive Indication

    When the service is requested for a non-contraceptive indication, document the diagnosis supporting the request.

    • Include the diagnosis for indications such as heavy menstrual bleeding
    Documentation Required

    Vasectomy Benefit Confirmation

    For vasectomy requests, confirm that the plan benefit or an applicable state mandate covers the service.

    • Document plan-benefit coverage or the applicable state mandate

    Unsupported block type: prior_auth

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: prior_auth

    Unsupported block type: billing_rule

    Denial Risk

    Adverse Determination Authority

    Automated systems and non-physician clinical reviewers may approve a request in full or in part but may never issue an adverse determination. Requests that do not meet criteria, including federally funded sterilization lacking required consent, age, or waiting-period requirements without an applicable exception, must be referred for physician review.

    • Only a licensed physician of the same or similar specialty may issue an adverse determination
    • Offer the requesting provider a peer-to-peer discussion before an adverse determination
    • Review supported portions separately when quantity, units, or duration exceed the documentation
    • The absence of a stated criterion is not itself a basis for an adverse determination

    Policy Background

    Female sterilization and FDA-approved intrauterine devices are included in federally mandated preventive contraceptive services supported by the HRSA Women’s Preventive Services Guidelines for applicable plans. Review confirms the member’s elected method and required documentation; it does not question the member’s decision.

    Definitions

    Female sterilization
    PurposeA surgical procedure intended to permanently prevent pregnancy.
    Fallopian tube methodsThe procedure may occlude, divide, or remove the fallopian tubes.
    Procedure typeFemale sterilization is a permanent contraception procedure.
    Integral service
    DefinitionAn item or service needed to deliver a covered preventive service.
    Clinical examplesExamples include anesthesia, facility charges, and a pregnancy test.
    Sterilization examplePathology for removed tubes is an integral service.
    Cost-sharing treatmentIntegral services are covered on the same no-cost-sharing basis as the covered preventive service.
    Federal sterilization consent rule
    Regulatory authorityThe rule consists of the consent requirements in 42 CFR Part 50, Subpart B.
    Applicable fundingIt applies to sterilizations performed in programs or projects supported by federal Public Health Service funding; a parallel rule applies to Medicaid-funded sterilizations.
    Age requirementThe individual must be at least 21 years old.
    Timing requirementsConsent must be obtained at least 30 days and not more than 180 days before sterilization, subject to a 72-hour exception for premature delivery or emergency abdominal surgery.
    Grandfathered plan
    Existence dateThe plan existed on March 23, 2010.
    Status requirementThe plan has retained its grandfathered status.
    Applicable exemptionA grandfathered plan is not subject to section 2713.