NCD 230.3

Indications and Limitations of Coverage

A. Nationally 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.

• Sterilization of a mentally challenged beneficiary is covered if it is a necessary part of the treatment of an illness or injury (bilateral oophorectomy or bilateral orchidectomy in a case of cancer of the prostate). The Medicare Administrative Contractor denies claims when the pathological evidence of the necessity to perform any such procedures to treat an illness or injury is absent; and

• 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. Nationally Non-Covered Conditions

• Elective hysterectomy, tubal ligation, and vasectomy, if the primary indication 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 Social Security 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.