(a) A hysterectomy performed for purposes of sterilization or family planning is not compensable. The 30 day waiting period which applies to elective sterilizations does not apply to therapeutic hysterectomies. Payment is made for therapeutic hysterectomies only when one of the following circumstances is met:
- (1) A properly completed hysterectomy acknowledgement is attached to the claim form. The acknowledgement must clearly state that the patient or her representative was informed, orally and in writing, prior to the surgery that she would be rendered permanently incapable of reproduction.
- (2) The surgeon must certify in writing that the patient was sterile prior to the surgery. The reason for the sterility, i.e., post-menopausal, previous tubal ligation, etc. must be given.
- (3) The surgeon must certify that the surgery was performed in an emergency, life endangering situation. The life endangering circumstances must be given.
(b) A hysterectomy acknowledgement form may be signed by the patient and dated after the surgery as long as the acknowledgement meets all other requirements. The patient must acknowledge in the form that prior to surgery she was advised orally and in writing that she would be rendered sterile as a result of the surgery.