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Author: Admin | 2025-04-28
Number: 0027 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References -->Policy Scope of PolicyThis Clinical Policy Bulletin addresses vasectomy procedures.Medical NecessityAetna considers vasectomy reversal medically necessary for the treatment of post-vasectomy pain syndrome if member has failed non-steroidal anti-inflammatory medications and local nerve blocks/steroid injections.Experimental, Investigational, or UnprovenThe following procedures are considered experimental, investigational, or unproven because there is inadequate evidence in the peer-reviewed published literature regarding their effectiveness (not an all-inclusive list):Vasectomy ProceduresEndoscopic vasectomyImplantable vas deferens ligation clip (Vasclip, VMBC, LLC, Roseville, MN)Pro-Vas occlusion methodVasal injection (e.g., reversible inhibition of sperm under guidance (RISUG)Vasal occlusion (e.g., Intra Vas Plug, and LigaSure);Procedures for Treatment of Post-Vasectomy Pain SyndromeEpididymectomyMicro-denervation of the spermatic cord. --> --> --> Table: CPT Codes / HCPCS Codes / ICD-10 Codes Code Code Description CPT Codes / HCPCS Codes / ICD-10 Codes --> CPT codes not covered for indications listed in the CPB: Implantable clip:(Vasclip, VMBC, LLC, Roseville, MN), Vessel Sealing Device (LigaSure) - no specific code: Endoscopic vasectomy - no specific code: ICD-10 codes not covered for indications listed in the CPB (not all-inclusive): N50.811, N50.812, N50.819 Testicular pain Z30.2 Encounter for sterilization Z98.52 Vasectomy status Vasectomy reversal procedures: CPT codes covered if selection criteria are met: 54860 Epididymectomy; unilateral 54861 bilateral 55400 Vasovasostomy, vasovasorrhaphy Other CPT codes related to the CPB: 52402 Cystourethroscopy with transurethral resection or incision of ejaculatory ducts 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) 89310 Semen analysis; motility and count (not including
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