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Medicare Coverage Database

NCD for Sterilization (230.3)

Publication Number

100-3

Manual Section Number

230.3

Version Number

1

Effective Date of this Version

This is a longstanding national coverage determination. The effective date of this version has not been posted.

Benefit Category

Physicians' Services

Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Coverage Topic

Hospital Care (Inpatient)
Outpatient Hospital Services

Indications and Limitations of Coverage

A - Covered Conditions

  • Payment may be made only where sterilization is a necessary part of the treatment of an illness or injury, e.g., removal of a uterus because of a tumor, removal of diseased ovaries (bilateral oophorectomy), or bilateral orchidectomy in a case of cancer of the prostate. Deny claims when the pathological evidence of the necessity to perform any such procedures to treat an illness or injury is absent; and
  • Sterilization of a mentally retarded beneficiary is covered if it is a necessary part of the treatment of an illness or injury.

Monitor such surgeries closely and obtain the information needed to determine whether in fact the surgery was performed as a means of treating an illness or injury or only to achieve sterilization.

B - Noncovered Conditions

  • Elective hysterectomy, tubal ligation, and vasectomy, if the stated reason for these procedures is sterilization;
  • A sterilization that is performed because a physician believes another pregnancy would endanger the overall general health of the woman is not considered to be reasonable and necessary for the diagnosis or treatment of illness or injury within the meaning of §1862(a)(1) of the Act. The same conclusion would apply where the sterilization is performed only as a measure to prevent the possible development of, or effect on, a mental condition should the individual become pregnant; and
  • Sterilization of a mentally retarded person where the purpose is to prevent conception, rather than the treatment of an illness or injury.

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Page Last Modified: 11/14/2008 11:24:36 AM

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