A4264 — Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical notes supporting that the patient is certain about desire for permanent sterilization (i.e., not uncertain about ending fertility) and has not had prior tubal ligation if hysteroscopic approach is being considered.
- Hysterosalpingogram is necessary three months after surgery to verify micro-insert placement and tubal occlusion (manufacturer labeling / prescribing information) — i.e., modified HSG confirmation testing at three months
- Catheterization and introduction of saline or contrast material for SIS or hysterosalpingography may be performed three months after hysteroscopic tubal sterilization to verify insert placement and tubal occlusion (CPT 58340) — documentation of performed imaging and results required when applicable
- Hysterosalpingography radiological supervision and interpretation documentation at three months after hysteroscopic tubal sterilization to verify insert placement and tubal occlusion (CPT 74740) — documentation of performed imaging and results required when applicable
Key Coverage Criteria
- Laparoscopy with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) when indicated (CPT 58661)
- Laparoscopy with lysis of adhesions with occlusion of oviducts by device (CPT 58671)
- Salpingectomy, complete or partial, unilateral or bilateral as separate procedure (CPT 58700)
- Catheterization and introduction of saline or contrast for saline infusion sonohysterography (SIS) or hysterosalpingography (HSG) (CPT 58340) — specifically allowed for confirmation (three months after hysteroscopic tubal sterilization to verify insert placement and tubal occlusion)
- Hysterosalpingography, radiological supervision and interpretation (CPT 74740) — specifically allowed three months after hysteroscopic tubal sterilization to verify insert placement and tubal occlusion
- ICD-10 diagnosis code Z30.2 (Encounter for sterilization) as covered diagnosis when selection criteria are met
1 Active Policy
AETNA-CPB-0657 — Tubal Sterilization
Related Codes
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