Does insurance (or Medicaid) cover tubal ligation reversal? How to get them to pay for it

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Did you have tubal ligation but want it reversed? You may want to have a child again or the ligation has caused complications.

So, you’re probably wondering if your insurance will cover all or part of the costs of the procedure.

The average cost of a tubal ligation reversal is around $8,000, but it may reach up to $21,000 depending on the pre-operation costs, where you’ll get the surgery, and any postoperative treatment you need to get.

Unfortunately, most insurance companies consider tubal reversal as elective surgery and will not pay for it unless it’s deemed medically necessary.

When Will Insurance Pay For Tubal Ligation Reversal?

Medicaid and private insurance companies may cover tubal reversal for up to $3,000 of the cost if there’s a proven medical need for it. You’ll have to pay for the rest.

There are three stages involved in this type of operation: testing stage, actual surgery, and post-operative treatment. 

Your insurer may cover the costs if they meet the following criteria.

Pre-Surgery Testing

Your insurer may cover pre-operative tests for your tubal reversal, such as the following:

  • Blood tests that identify infections, such as STD, HIV, or Hepatitis
  • Ultrasound and exam that show the health of your reproductive organs

Actual Surgical Procedure

Your insurer may cover the procedure if it addresses an underlying medical condition that may have been caused by the prior tubal ligation procedure, such as:

  • Post Tubal Ligation Syndrome (PTLS)
  • Dysmenorrhea
  • Other related services rendered during the operation, such as the removal of polyps or uterine fibroids

Post-Operative Treatment

Insurance companies may cover treatments for complications that may arise from the tubal reversal surgery, such as:

  • Infection
  • Bleeding
  • Damage to nearby internal organs
  • Severe reactions to anesthesia

The tubal reversal operation is safe. But when things go wrong, Medicaid and private insurers may cover the expenses needed for your post-treatment, as long as it’s covered by a medical reason.

How Can You Check If Your Insurance Covers Tubal Reversal?

You pay monthly premiums for your insurance policy and in return, they cover your expenses that are medically necessary. You can find a list of what’s covered under your policy in the contract that you’ve signed with your insurance company.

A standard health insurance coverage includes medical expenses that are proven to be necessary. Anything that’s not medically required, such as plastic and cosmetic surgeries, isn’t covered.

Most insurance companies consider tubal ligation reversal as non-life-threatening and don’t require immediate medical attention. If you want to find out if your insurance company covers this operation, you should undergo pre-verification.

What Is Pre-verification And What Are The Requirements?

Pre-verification is a process wherein the insurance company will determine if the medical operation is covered by your insurance plan.

You may have to provide your insurer with the following:

Medical Codes for Tubal Reversal

You have to provide your insurer with the medical code for the procedure, namely the CD-10 diagnosis code and the CPT surgical procedure code.

Letter Proving Medical Necessity

In some instances, your insurance company will require a letter from your doctor saying that the procedure is a medical necessity. It’s your responsibility to secure pre-certification or pre-authorization.

Ask your primary care doctor that you need a letter that proves the procedure is a medical necessity. In the letter provided by your doctor, your systems will be described, as well as your diagnosis and an explanation of why tubal reversal is required.

Be sure to be pre-verified before you get the operation so you’ll know if you’re covered or not and what are out-of-pocket costs you need to pay.

How To Get Reimbursement For The Tubal Reversal Operation?

It’s good news if your insurance company tells you that your tubal reversal operation is covered. In most cases, you need to pay for the costs first.

You have to download the Member Claim Form from the website of your health insurance provider. Call their customer service support if you need assistance.

Fill out the form including all the codes required.

Once the surgery is done, your health care provider will give you the medical codes based on their findings during your surgery. 

They’ll also provide you with other important documents, such as the receipt for your surgery and the code sheet for the diagnosis and procedure.

Submit the necessary documents, including the Member Claim Form, to your insurance company to be reimbursed for your expenses.

Does Medicaid Cover The Costs Of Your Tubal Ligation Reversal?

Medicaid may cover certain parts of your tubal ligation reversal surgery costs if the operation is considered medically necessary. 

In general, Medicaid won’t cover tube untying because it’s a reversal of an operation that you decided to have voluntarily, even though there was no medical need for it. It’s therefore not deemed to be essential or necessary by your insurance company.

But if the procedure will prevent or treat a medical symptom, injury, or disease, then Medicaid may decide to cover the cost of the operation. These include the following:

  • Increased cramping during menstrual periods
  • Continued pelvic pain
  • Depression
  • Obesity and more bloating
  • Damaged bladder
  • Damaged bowel
  • Damaged blood vessels

How To Lower Your Cost For A Tubal Ligation Reversal Surgery?

If your insurance company won’t cover the operation, there are things you can do to lower the cost of your tubal ligation surgery.

Stick To Basic Services

Get only the most basic services like a simple procedure to untie your tubes. It means no optional test before the surgery and no other treatments after the operation.

Apply For Government Grants

The federal government provides funding to state agencies, universities, and other non-profit groups so they can provide financial assistance to people who need to undergo medical procedures. We haven’t found any examples yet.

You should check Grants.gov if there are local agencies or organizations in your area offering government grants.

Look For Private Grants

Sometimes, private non-profit organizations, such as the Cade Foundation, may offer tubal ligation reversal grants to couples with low income. 

Unfortunately, these groups have limited funding and resources, which means they can only help a few families.

Apply For Financing From Third-Party Companies

You may apply for a medical loan from United Medical Credit or CareCredit. Medical loans are unsecured financial loans that you can use to cover your health care costs. 

Securing financial assistance is an option to consider if your tubal reversal operation isn’t covered by your insurance company. It gives you access to the amount you need if you don’t have enough cash to cover the full amount of your operation upfront. 

Apply For FSA Loans

A Flexible Spending Account (FSA), through your employer, may help you finance your tubal reversal operation. 

Schedule your surgery at the beginning of the FSA plan year and your employer will cover all qualifying costs. You’ll have 12 months to repay your loan to your employer.

Conclusion

Tubal reversal surgery is expensive and rarely covered by insurance companies and Medicaid unless it’s a medical necessity. The costs of pre-operative tests, the actual surgery, and post-operative treatments may be covered if they’re proven to be medically necessary.

You should go through the pre-verification process first with your insurer to know if your operation will be covered or not. Once you’re done with your surgery, you can submit the necessary documentation to your insurer so you can get a reimbursement. 

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