As women continue to experience Essure complications at high rates, more and more patients are beginning to investigate the idea of having their birth control implants removed.

Essure & Insurance: A Basic Guide To A Complex Problem

In an earlier article, we wrote about how difficult removing Essure implants can be, along with the serious lack of surgeons experienced in removal procedures and the considerable disagreements in the medical community about how best to take the implants out. It’s an unfortunate fact that, since Essure was designed to be a permanent contraceptive option, medical researchers have thus far neglected to study reversing the implant’s effects with any rigor.

Doctors Discuss Treatment Plan

Today, we’ll turn to an associated issue – getting an insurance company to pay for your Essure removal procedure. The short to the question posed by this article is sometimes. Whether or not an insurer will cover Essure removal is a matter of what procedure you plan to undergo, what insurance company you have and how vigorous your physician turns out be in fighting your insurer for approval.

(Most) Insurers Are Required To Cover Essure Placement

Since 2012, all insurance plans (both private and those purchased through an Obamacare marketplace) are required to cover the full roster of birth control options approved by the Food & Drug Administration. That mandate included Essure, a permanent birth control implant that secured the FDA’s pre-market approval in 2002. While some older policies were “grandfathered” in without the contraceptive mandate, most insurance plans today must cover Essure implant placement and follow-up care without asking patients to contribute co-payments.

More recent rules from the Trump Administration have changed the picture somewhat, allowing insurers and employers to refuse coverage for contraception when it conflicts with their “religious beliefs” or “moral convictions.” Despite the revision, it remains true that the majority of major insurance companies are required, by law, to cover Essure implants.

Surgeon Says Getting Insurance Coverage Is Difficult

That all changes when we start to consider removing or reversing the placement of Essure implants, according to A Personal Choice, one of the nation’s leading fertility surgeon practices.

Dr. Charles Monteith, Medical Director at A Personal Choice, has been reversing tubal ligation procedures for nearly a decade. When Essure patients began to approach with him debilitating side effects, he turned to focus on developing techniques to reversing hysteroscopic tubal sterilization, the class of medical procedures under which Essure falls. Dr. Monteith says he decided, after years of successful practice as an OBGYN, to “help those who other doctors would not or could not help.”

Essure patients were at the top of the list. But that also means Dr. Monteith has extensive experience helping patients have their removal or reversal procedures covered by insurance. Unfortunately, Dr. Monteith reports that only a portion of his patients have been able to secure coverage for Essure reversal procedures and, in the majority of those cases, the coverage has only been partial. The highest reimbursement rate Dr. Monteith has seen was around 50% of the procedure’s total cost.

Removal Vs. Reversal Procedures

In the end, health insurance coverage will depend primarily on the type of procedure you’re undergoing. Before we move further, we should distinguish two different ways Essure can be taken out:

  • More invasive procedures, in which the Fallopian tubes are removed (either partially or entirely), are known as Essure removal procedures. Hysterectomy and salpingectomy, in which the Fallopian tubes are removed, are two common examples.
  • Operations in which the implants are removed, but the reproductive organs are reconstructed afterward, are called Essure reversal procedures. When successful, reversal procedures allow women to become pregnant. This operation is usually referred to as a tubouterine implantation.

This distinction drives us directly into our first problem. As Dr. Monteith notes, the majority of health insurance companies consider Essure reversal surgeries to be elective procedures undertaken for fertility purposes. And most insurers don’t cover fertility treatments at all. So it’s unlikely, from the start, that a reversal procedure will be covered by your insurance company.

Medically-Necessary Essure Removal

Removal procedures, on the other hand, are usually performed to stop the debilitating symptoms and side effects to which Essure implants have been linked. That goal places Essure removal procedures outside the category of fertility treatments and some insurers will now recognize the medical necessity of an Essure removal operation when a patient’s symptoms are properly-documented.

So operations like a hysterectomy or salpingectomy, when performed in a hospital, could be covered. But that’s not a guarantee. Hysterectomy procedures, for example, are often considered elective, unless the operation is performed on a doctor’s orders to remove uterine cancer or stop internal bleeding.

Thus many insurance companies will deny an initial request for hysterectomy coverage, forcing physicians to appeal the insurer’s initial decision. The Essure Problems website is filled with stories of women who were denied coverage for a hysterectomy procedure, even though an implant had perforated their vital organs.