Does Health Insurance Cover Tubal Ligation Reversal?

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Does Health Insurance Cover Tubal Ligation Reversal?

How do you get your tubes untied with Medicaid? How do you get your private insurance plan or company to pay for tubal ligation reversal surgery?

Surprisingly, the answer to both of these questions is the same – it will be very hard.

Here is the bottom line. Both Medicaid and private insurance plans may pay when there is a covered medical reason for each possible step: upfront testing, the procedure itself, and any post-operative issues.

In addition, supplemental policies and state-based infertility mandates open the door for alternative approaches. These avenues could be a more affordable way to restore your fertility and have another baby – or two.

Get Your Tubes Untied With Medicaid

How do you get your tubes untied with Medicaid? Medicaid is a public health insurance plan for low-income families, women, and children. The federal government provides much of the funding, and each state administers the programs and set rules for eligibility and coverage.

In general, Medicaid will not pay for tubal reversal surgery in any state unless you can cite a medically necessary reason. Therefore, getting your tubes untied with Medicaid may mean finding alternatives.

Covered Medical Reasons

Medicaid and other private insurance plans may pay for three types of covered medical reasons relating to your pending tubal reversal procedure. Each phase or category must be medically necessary. Medically necessary means that procedure prevents, diagnoses, or treats an injury, disease, or symptoms.

Pre-Surgery Testing

You may be able to get your Medicaid or private insurance plan to cover certain tubal reversal pre-surgery testing steps. Ask your clinic to code the test for a medically necessary reason.

  • Pre-operative bloodwork to spot infections (STD, HIV, or Hepatitis)
  • Ultrasound and exam to visualize the health of reproductive organs

Surgical Procedure

It is unlikely that your Medicaid or private insurance plan will cover the tubal reversal surgery itself as it corrects earlier voluntary sterilization. The purpose is rarely a covered medical reason – unless the procedure corrects an underlying disease or symptom.

  • Post Tubal Ligation Syndrome (PTLS) is the rapid decline of estrogen/progesterone hormone levels caused by damaged blood supplies to the ovaries
  • Dysmenorrhea is pain and cramping during your menstrual cycle

Also, related services rendered while under the knife might be covered. For example, removal of uterine fibroids and polyps could be medically necessary and needed to restore fertility.

Post-Operative

It is more likely that your Medical or private insurance policy will cover any complications arising from your tubal reversal operation. The surgery is very safe. However, things can go wrong and these complications are often covered medical reasons.

  • Bleeding
  • Infection
  • Damage to nearby organs
  • Reactions to anesthesia

Get Private Insurance To Pay for Tubal Reversal

How do you get your health insurance plan to pay for tubal ligation reversal surgery? Follow the same logic as for Medicaid plans – specify the medically necessary portions of the procedure (upfront testing, PTLS or Dysmenorrhea, post-operative complications).

However, health insurance plans issued in the private marketplace offer two possible opportunities to make having a baby again more affordable.

  1. Supplemental policies cover the expected outcome
  2. Infertility mandates may cover other treatment options

Supplemental Insurance

Supplemental health insurance covers tubal reversal outcomes – not the surgical procedure itself. Remember, the purpose of this procedure is to restore your fertility and have another baby.

Therefore, you may need to take unpaid maternity leave and find yourself with leftover hospital bills after your labor and delivery.

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Sterilization Reversal - A Generous Act of Love [PDF] 2003 edition

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