55250
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.29
Facility
$218.11
Non-Facility
$346.70
Documentation Required
- Medical records and pathology reports demonstrating disease or injury and documenting that the procedure's primary objective was treatment (not sterilization) are required to support coverage.
- Claims lacking pathological evidence of necessity are subject to postpayment review and recoupment.
- Legal/regulatory citations applicable to coverage determinations include Section 1862(a)(1)(A) of the Social Security Act and 42 CFR 411.15(k), which govern payment exclusions for procedures lacking medical necessity.
- Medical record must include pathological evidence demonstrating that the sterilization procedure was necessary to treat an illness or injury.
Key Coverage Criteria
- Sterilization procedures are covered when they are necessary to treat an illness or injury rather than performed solely to cause permanent infertility.
- Hysterectomy performed to remove a uterus because of a tumor is covered when the primary objective is treatment of the disease.
- Bilateral oophorectomy (removal of diseased ovaries) is covered when performed to treat ovarian disease such as a tumor.
- Bilateral orchiectomy is covered when performed as necessary treatment for prostate cancer or other testicular disease where removal is therapeutic.
- Bilateral orchiectomy is covered when performed to treat conditions such as prostate cancer.
- Sterilization is covered when performed as necessary treatment of an illness or injury and the primary objective is treatment rather than achieving sterilization.
3 Active Policies
A59060 — Sterilization
J06
A53356 — Sterilization
AETNA-CPB-0027 — Vasectomy Procedures
Related Codes
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