r/sterilization • u/cyncynnamon • Mar 12 '25
Insurance “No pre-approval required” does this mean it’s covered?
I’m so confused… called insurance yesterday and they said that my bisalp (CPT 58661) isn’t covered, like I’d have to pay up until my deductible (like $8K), then insurance would cover 50% after that and I pay the other 50%… they didn’t know what to do with the Z30.2 diagnostic code (or what even that was), but kept saying it would only be covered if it’s officially preventive care.
So anyways, I message the surgery scheduler asking for confirmation that those codes would be used and she just keeps saying “you’re good to go cause no pre-approval is required”… well yea, of course insurance would LET ME do it, doesn’t mean they’re gonna pay right??
Me: “As far as I understand, if the CPT code 58661 is used together with the Z30.2 diagnostic code, then that should go through as preventive care, which should be covered by my insurance I believe. Could you please confirm those are the codes that will be used?”
Scheduler: “Good morning, I was out of the office yesterday, but per my previous message sent to you on 2/28/25, I did do the pre-approval check for your upcoming surgery with your insurance, KY Wellcare, and no pre-approval was required.
The CPT code that was given to you is the correct CPT code for your procedure. The diagnosis code provided to you was not the code provided by Dr. Gursahaney therefore it was not cannot be used. There are multiple diagnosis codes that can be utilized for surgery.
Again, you are all set and ready to go for April 7th insurance wise.”
??? Am I understanding this wrong or what haha
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u/Free-Government5162 Mar 12 '25
My understanding is that pre-approval/not needing one just means you are allowed to have the surgery and don't need to run it past your insurance for them to determine if you need it/that they will fully deny your claim if they decide you don't. I do not believe it guarantees any coverage different than what you were told.
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u/cyncynnamon Mar 12 '25
Right!! Okay, I sent her another message trying to clarify even more… she never answers my questions, just says I’m good to go. Hope she doesn’t get pissed and cancels my surgery or something 😅
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u/jaydizzle46 Mar 12 '25
You need answers from your insurance company not the hospital staff.
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u/cyncynnamon Mar 13 '25
All insurance said was 58661 wasnt preventive so it was gonna cost me… and they didn’t know what a diagnosis code was or what to do with it (and that was speaking to a member of the escalation team)… generally so clueless but I can keep trying!
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u/asstlib Mar 13 '25
Doesn't guarantee coverage. Still need the surgery scheduler to confirm what the coverage is for the procedure in order to avoid a costly surprise.
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u/cyncynnamon Mar 13 '25
Gotcha! Yea and all she says is “looks like no pre-approval is required, so we’re good” but like ??? That doesn’t help me at all, I need to know specifics… seems like most people in this subreddit can get it for free though so idk if in my case it isn’t free, or if everyone I’m talking to just doesn’t know what’s going on… my insurance is ACA compliant and their handbook says if sterilization is preventive then it should be free… next step for me I guess is so wait until the doctor gets back from vacay so she can tell me what soecific codes will be used to make sure it’ll be coded as preventive…
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u/toomuchtodotoday Mar 13 '25
Useful links related to insurance coverage. If your plan is ACA compliant, a bisalp should be covered at 100% as preventative care.
https://tubalfacts.com/post/175415596192/insurance-sterilization-aca-contraceptive-birth-control
https://nwlc.org/tips-from-the-coverher-hotline-navigating-coverage-for-female-sterilization-surgery/ "Any related services—like anesthesia—must be covered as well. The most recent guidance from federal agencies makes it explicitly clear that anesthesia and other related services like doctor’s appointments must be covered by the insurance plan at 100% of the cost."
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