Status: Bilateral salpingectomy scheduled! ...10.5 years after my tubal ligation
After confirming insurance coverage on 3/7, I found myself experiencing hesitation about the additional surgery. Also, I have grief over not being able to get a salpingectomy back in 2013 despite knowing it was the better sterilization procedure. This grief is something I'll continue to process, even as I've decided to move forward.
On 4/24, after a month-and-a-half of unproductive overthinking, I finally decided to move forward and called my doctor's office. I wish I'd moved on this sooner.
On Thursday 5/2, I had my pre-op appointment, after which I signed the consent form for my laparoscopic bilateral salpingectomy. There was only one consent form this time--no sterilization-specific consent forms.
On Monday 5/6, the surgery scheduler from my doctor's office called me with a date. My bilateral salpingectomy will be just over two months from 5/6. It'll be over 10.5 years after my tubal ligation.
Note: for unrelated reasons, I decided to postpone the endometrial ablation to a later time.
Insurance: Details about Marketplace plans that were available to me
Based on notes I took while deciding on my new insurance plan, here are some limited details about Marketplace plans that were available to me in the state of Michigan. You may or may not have the same plans available.
Blue Cross Blue Shield PPO
-- Purchase decision: ✅
-- Certificate of Coverage published: ✅
-- -- No stated "one per lifetime" limitation on sterilization: ✅
-- -- Coverage for treatment of complications related to non-covered services: Doesn't exclude coverage: ✅
-- No referral to see specialist: ✅
-- Key providers and facilities in-network: ✅
-- Available plans: Secure, Extra, HSA
-- Reject reason: None
Blue Care Network HMO
-- Purchase decision: ❌
-- Certificate of Coverage published: ✅
-- -- No stated "one per lifetime" limitation on sterilization: ✅
-- -- Coverage for treatment of complications related to non-covered services: Doesn't exclude coverage: ✅
-- No referral to see specialist: ❌
-- Key providers and facilities in-network: ✅
-- Available plans: Select, Preferred, Local, Metro Detroit; some of these weren't available in my region
-- Reject reason: Need referral to see specialist
UnitedHealthcare HMO
-- Purchase decision: ❌
-- Certificate of Coverage published: ✅
-- -- No stated "one per lifetime" limitation on sterilization: ✅
-- -- Coverage for treatment of complications related to non-covered services: Explicitly includes coverage: ✅✅
-- No referral to see specialist: ❌
-- Key providers and facilities in-network: ❌
-- Reject reason: Need referral to see specialist; Key providers and facilities out-of-network, with smaller network overall
Molina Marketplace HMO
-- Purchase decision: ❌
-- Certificate of Coverage published: ✅
-- -- No stated "one per lifetime" limitation on sterilization: ✅
-- -- Coverage for treatment of complications related to non-covered services: Explicitly includes coverage: ✅✅
-- No referral to see specialist: ✅
-- Key providers and facilities in-network: ❌
-- Reject reason: Key providers and facilities out-of-network
MyPriority Health HMO
-- Purchase decision: ❌
-- Certificate of Coverage published: ❌
-- No referral to see specialist: ✅
-- Key providers and facilities in-network: ✅
-- Reject reason: Certificate of Coverage not published
McLaren HMO
-- Purchase decision: ❌
-- Certificate of Coverage published: ❌
-- No referral to see specialist: ✅
-- Key providers and facilities in-network: ✅
-- Reject reason: Certificate of Coverage not published
Insurance: New insurer confirms best-case scenario!
Today 3/7, I called my new Marketplace plan. 6 weeks after starting this process, I have an answer.
And it's basically the best-case scenario.
When the representative picked up, I opened by asking "I have a combination of procedure code and diagnosis code. Can I check if it's covered?"
The representative said yes and asked me for the procedure code. I said 58661 [Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)]. Next, the representative asked me for the diagnosis code. I said Z30.2 [Encounter for sterilization]--I spelled it out as "Z as in Zulu three zero decimal two", just for clarity. He confirmed the procedure code is "removal of adnexal structures" and I said that was correct. Then, as expected, he confirmed that it's covered. No surprises so far, but I needed to know more than just that.
Next, the representative said there were some conditions on this coverage. The first three conditions were standard conditions regarding the types of facilities and medical professionals that would be covered.
Then, the representative read a fourth condition to me: "The first procedure per lifetime will be covered 100% by [insurer] without cost-sharing. After that, subsequent procedures will be subject to deductible and coinsurance." Note: I hadn't yet mentioned my prior sterilization procedure or asked about a possible "one per lifetime" limitation.
The representative continued that pre-authorization is not required for procedure code 58661 regardless of diagnosis code. I asked about documentation a bit later--thinking they might need proof of sterilization failure or reversal to cover a second procedure--and the representative said that my provider would not need to supply any documentation.
After that, I asked my follow-up question: "I actually had a question about the 'first per lifetime' thing. I already had a different procedure code under the same diagnosis code Z30.2 back in 2013. You're saying that if I had another procedure under Z30.2 this year, it would be covered subject to deductible and coinsurance?"
The representative first confirmed "You are saying you already had a different procedure in 2013 under the Z30.2 diagnosis code?" I said that was correct. He confirmed again that the previous procedure was under a different procedure code but same diagnosis code, and I confirmed that was correct. The representative then said, "OK. Only the first procedure under Z30.2 will be covered 100% by [insurer]. Since this would be your second procedure under Z30.2, it will be covered subject to deductible and coinsurance."
After that, the representative told me my deductible and out-of-pocket max, which are the same because there's no coinsurance under this particular plan.
I can't believe it. To me, this is basically the best-case scenario. This Marketplace plan has a "one per lifetime" limitation on the preventive benefit of 100% coverage, but subsequent procedures are still covered subject to deductible and coinsurance. I'd already figured I wouldn't get 100% coverage again anyway, and I'm fine with it. It was actually the same insurer who paid for everything back in 2013, at a time in my life when I wouldn't have been able to pay.
Insurance: Questions to ask my new Marketplace plan
Below is an approximate tree of questions I intend to ask my insurer.
# Ask: Can procedure code 58661 [Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)] be covered under diagnosis code Z30.2 [Encounter for sterilization]?
YES is expected. This only confirms they cover salpingectomy as sterilization, which is the norm among insurers by now.
## If YES, ask: Is coverage under diagnosis code Z30.2 limited to one procedure per lifetime?
### If YES, ask: Can procedure code 58661 be covered under diagnosis code Z80.41 [Family history of malignant neoplasm of ovary]?
#### If YES, ask: What, if any, documentation do I need to provide?
#### If NO, ask: Let's say I self-pay for the procedure itself. If there was a complication resulting from the procedure, would treatment of that complication be covered?
### If NO, get confirmation: I've already had a procedure under diagnosis code Z30.2 back in 2013. If I had another one this year, would it be covered?
Insurance: Marketplace plan purchased, but can't confirm coverage details until next week.
Today 2/29, I made my final selection among the Marketplace plans and paid my first premium. I've confirmed with my new insurer that they've received my payment and my plan will be effective 3/1. This is critical because I need to switch to a Marketplace plan effective 3/1 anyway for normal reasons.
However, they can't provide specific details about my coverage yet. I was told to call back next week once my account is fully set up. Fair enough.
Insurance: Certificates of Coverage for Marketplace plans -- is there no "one per lifetime" limitation?
I'll need to switch to a Marketplace plan effective 3/1 anyway, so I've been shopping for a plan.
What's a Certificate of Coverage?
Here's a good working definition: "A certificate of coverage is an official contract that outlines what an insured is entitled to, and what they aren't insured for, under a health insurance policy."
Of the Marketplace plans available to me, most haven't published Certificates of Coverage, but some have. In my unusual situation, I can only consider Marketplace plans that have published Certificates of Coverage.
Implications of Certificates of Coverage
Regarding the possibility of self-pay:
Some of the Marketplace plans' Certificates explicitly include coverage for treatment of complications related to non-covered services. Notably, none of them exclude this coverage. In contrast, my current private insurance plan explicitly excludes this coverage.
Regarding possible coverage as sterilization:
Under my current private insurance plan, coverage of sterilization under diagnosis code Z30.2 [Encounter for sterilization] is limited to one procedure per member per lifetime. However, these Marketplace plans' Certificates don't state the same limitation. Certificates are contracts, and typically insurers try to exclude everything they can; so, while the absence of an exclusion doesn't imply an inclusion, it's a good sign.
I also noticed that certain other procedures--like bariatric surgery, for example--are limited to one procedure per member per lifetime by these Marketplace plans' Certificates. That tells me that Marketplace plans can impose "one per lifetime" limitations in general, which makes it more notable that there is no stated "one per lifetime" limitation on sterilization coverage.
No stated limitation--I can't be sure yet that there is truly no such limitation, however.
Regarding possible coverage under gender-affirming care:
All Marketplace plans available to me cover gender-affirming care, so this is still a potential route.
Additional considerations
Network: I can only consider Marketplace plans under which all relevant providers and facilities are in-network.
No referral to see a specialist: I can only consider Marketplace plans that don't require a referral from a PCP to see a specialist. I haven't involved my PCP in this process at all. I'd prefer to keep it that way, even if it means I have to pay more for a PPO plan.
Insurance: Possible update re: diagnosis code F64.9 [gender dysphoria]
I heard back today 2/13 from a gender-affirming care clinic in my metro area that sees many patients for gender-affirming surgery referrals. They believe that procedure code 58661 [Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)] can be covered under diagnosis code F64.9 [gender dysphoria]. They are also able to provide me with therapist letters to meet my insurer's requirements for coverage.
I believe the clinic is correct that procedure code 58661 can be covered under diagnosis code F64.9. But I still suspect that this coverage is intended to cover oophorectomy with or without salpingectomy, but not salpingectomy alone.
Insurance: Do Marketplace plans cover treatment of complications related to non-covered services?
Accuracy TBD, but I recently read that Marketplace plans are required to cover treatment of complications related to non-covered services. Meaning: if you self-pay for a non-covered service, and you have a complication related to that non-covered service, the plan would cover treatment of that complication, even though it didn't cover the non-covered service.
Generally speaking, private insurance plans explicitly exclude this same coverage. For example, my current private insurance plan through my former employer explicitly excludes coverage for treatment of complications related to non-covered services.
Today 2/5, I called the Marketplace and the representative I spoke to seemed to confirm it: "They won't cover remedial and revisions, but they'll cover hospitalizations and things like that."
Earlier today, I registered through HealthCare.gov to be contacted by an insurance broker. A broker already contacted me and I asked the same question. The broker quickly confirmed that "Covered services are medically necessary procedures. They may be a result of something not covered."
Well, at least it's a possible path. I'll need to switch to a Marketplace plan effective 3/1 anyway. Of course, I would need to check the specific plans I consider. I could negotiate rates and self-pay for the surgery, while relying on a Marketplace plan to cover treatment of complications just in case.
Yesterday 1/25, I contacted my insurer. I'm currently on a private insurance plan through my former employer.
Sterilization
My insurance plan won't cover a second procedure under diagnosis code Z30.2 [Encounter for sterilization]. Their coverage of sterilization under diagnosis code Z30.2 is limited to one procedure per member per lifetime.
Cancer prevention / family history
My first priority was to check if procedure code 58661 [Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)] could be covered under diagnosis code Z80.41 [Family history of malignant neoplasm of ovary]. The representative I spoke to confirmed that this service has the ability to be covered, but pre-authorization is required. Certain requirements must be met to prove medical necessity. Without sharing too much family/personal info, I'll just say that I don't quite meet the requirements.
I thought this might happen, so I was prepared with a backup option.
Gender dysphoria
My second priority was to check if procedure code 58661 could be covered under diagnosis code F64.9 [gender dysphoria]. The representative confirmed that this service also has the ability to be covered, but as before, pre-authorization is required. Certain requirements must be met to prove medical necessity, and this time, I'd be able to meet the requirements. They're the same requirements I'd have to meet for coverage of hysterectomy under diagnosis code F64.9. Also, I've already been diagnosed with gender dysphoria.
Well, that's not bad! At least it's something.
But since I'll need the same kind of therapist letters either way, I might as well get a hysterectomy.
Moreover, I suspect that this coverage of procedure code 58661 under diagnosis code F64.9 is intended to cover oophorectomy with or without salpingectomy--i.e. removal of ovary, with or without removal of tube--but not salpingectomy alone. I have a feeling that it won't work out in the end. I can't be sure, and maybe it's still worth a shot.
For much of last year 2023, I'd been planning to pursue a hysterectomy this year as gender-affirming care. Specifically, I wanted a total hysterectomy with bilateral salpingectomy, i.e. removal of my uterus, cervix, and fallopian tubes.
How it's going
Over the last couple weeks as of the time of writing (1/13), I read many positive experiences from people who had bilateral salpingectomy and endometrial ablation within the last few years. They ranged 28-36 years old, so similar age range to me; I'm 33.
Great, I thought. Maybe I'll get an ablation instead of a hysterectomy ... but, well, to be honest, I'd still also want the salpingectomy.
Why it's not the usual situation
With respect to the salpingectomy, the complicating factor is that I've already been sterilized. If I'd been able to get a salpingectomy instead of a tubal ligation when I was sterilized in 2013, I thought maybe I'd be fine with getting an ablation instead of a hysterectomy. This is purely to do with efficacy--I've had no issues/complications related to my tubal ligation.
Then, I thought, if it's possible for me to still get a salpingectomy now, salpingectomy + ablation is still lower-risk than hysterectomy.
There's also the recovery. While I'd love to evict my uterus, hysterectomy recovery is too intense and prolonged. From experience, recovery from sterilization surgery is much easier.
The problem is insurance coverage; will my insurance cover a salpingectomy for a patient who has already been sterilized?
I guess we'll find out.
Why I didn't get a salpingectomy in 2013
For context, I had my tubal ligation in 2013. Even back in 2013, I knew that salpingectomy was the better sterilization procedure. I knew salpingectomy was virtually 100% effective as a method of birth control, with a failure rate of virtually zero. Also, I'd seen research indicating that most ovarian cancers originate in the fallopian tubes. Through the internet, I was aware of salpingectomies being done for sterilization at that time--mostly in British Columbia, Canada--though they weren't common yet. All of this led me to conclude, even in 2013, that my preferred method of sterilization was complete bilateral salpingectomy.
Unfortunately, salpingectomy wasn't the standard of care for sterilization at the time. My health insurance at the time didn't consider salpingectomy to be a sterilization procedure at all, so they wouldn't cover it at all--zero coverage. Even in hindsight, I can't fault my then-insurer for not covering a then-nonstandard procedure.
Topics intentionally omitted from this blog
Topics better discussed with your doctor: details about medical procedures, surgery, risks, recovery, etc.
Details of my own medical appointments unless strictly relevant to potential readers.
Details about costs: Insurance and healthcare costs vary greatly by state/region, insurer, number of dependents, amount of subsidy if applicable, and other details.
Details about personal factors/motivations: I touched on it briefly above, but I won't get into it more unless strictly relevant to potential readers.
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