54861
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
9.46
Facility
$520.05
Non-Facility
$520.05
Documentation Required
- Clinical records supporting the diagnosis of post-vasectomy pain syndrome (history, pain duration, prior treatments, response to spermatic cord block if performed) — inferred from the policy statements describing required failed therapies and typical workup prior to surgery.
- Documentation that the member has failed non-steroidal anti-inflammatory medications and local nerve blocks/steroid injections (per Medical Necessity statement).
- Documentation that "selection criteria are met" for covered vasectomy reversal procedures (CPT 55400) and for epididymectomy (CPT 54860, 54861) when those CPTs are billed (policy notes these CPTs are "covered if selection criteria are met").
- Use of ICD-10 code G89.28 (Other chronic postprocedural pain [post-vasectomy]) when applicable to indicate covered diagnosis.
Key Coverage Criteria
- Stopping other contraception: "Patients may stop using other methods of contraception when 1 un-centrifuged fresh semen specimen shows azoospermia or less than or equal to 100,000 non-motile sperm/ml." (policy background guidance)
- Aetna considers vasectomy reversal medically necessary for the treatment of post-vasectomy pain syndrome if member has failed non-steroidal anti-inflammatory medications and local nerve blocks/steroid injections.
- Vasectomy reversal procedures (CPT 55400) — covered if selection criteria are met.
- Epididymectomy (CPT 54860 unilateral; 54861 bilateral) — covered if selection criteria are met.
- ICD-10 code G89.28 (Other chronic postprocedural pain [post-vasectomy]) — listed as an ICD-10 code covered if selection criteria are met.
1 Active Policy
AETNA-CPB-0027 — Vasectomy Procedures
Related Codes
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