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    v1.0.30
    OpenPayerPolicy UpdatesReproductive Health & FertilityAetna Transcervical Balloon Tuboplasty Coverage | …
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    CurrentAetnaPolicy 0347

    Transcervical Balloon Tuboplasty

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    Defines Aetna's coverage policy for transcervical balloon tuboplasty for members with infertility due to proximal tubal occlusion and states investigational status for other indications.

    Policy Summary
    PayerAetna
    PolicyTranscervical Balloon Tuboplasty
    Policy CodePolicy 0347
    Change TypeNo material changes
    Effective DateAug 27, 1999
    Last ReviewMay 30, 2023
    Next Review DateMar 28, 2024
    Key ActionObtain prior authorization when billing CPT 58345 and document proximal tubal occlusion on hysterosalpingogram with infertility diagnosis.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1Covered clinical indication
    YesExperimental for other indications
    58345

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    Key procedure code
    N97.1Referenced diagnosis
    1999Policy active since

    Coverage Criteria

    Medical Necessity — Covered when ALL of the following are met:

    Covered when ALL of the following are met:

    Covered indication: Member has infertility due to a proximal tubal occlusion demonstrated on hysterosalpingogram.

    ICD-10 N97.1 supports the diagnosis

    Experimental and Investigational — Not covered when ANY of the following apply:

    Not covered when ANY of the following apply:

    Experimental/Investigational: Indications other than infertility due to proximal tubal occlusion.

    Effectiveness not established for other indications.

    Transcervical balloon tuboplasty is considered experimental and investigational for any indication other than treatment of infertility due to a proximal tubal occlusion demonstrated on hysterosalpingogram. This means procedures performed for non‑infertility indications or for tubal pathology other than a proximally located occlusion are not supported by established evidence of effectiveness.

    Any use of transcervical balloon tuboplasty outside the specified covered indication may be denied as not medically necessary because its effectiveness for other clinical situations has not been established. Providers should therefore limit requests for authorization and claims to patients meeting the documented selection criteria for infertility due to proximal tubal occlusion.

    Coding

    Covered CPT Codes (if selection criteria met)CPTCovered
    58345Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography.
    Other related CPT CodesCPT
    58340Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography.
    74740Hysterosalpingography, radiological supervision and interpretation.
    74742Transcervical catheterization of fallopian tube, radiological supervision and interpretation.
    76831Saline infusion sonohysterography (SIS), including color flow Doppler, when performed.
    Related HCPCS CodesHCPCS
    A9574Air polymer-type a intrauterine foam, 0.1 ml.
    Relevant ICD-10 CodesICD-10
    N97.1Female infertility of tubal origin

    Provider Actions & Billing

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for CPT 58345 when billing for transcervical balloon tuboplasty. Submit a prior authorization request demonstrating that the member meets the policy selection criteria for coverage.

    • Affected CPT: 58345 — Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography.
    Denial Risk

    Experimental Indications May Be Denied

    Transcervical balloon tuboplasty and other selective salpingography maneuvers are considered experimental/investigational for indications other than infertility due to proximal tubal occlusion. Requests for procedures for other indications may be denied.

    • Denial risk applies when indication is not proximal tubal occlusion demonstrated on hysterosalpingogram.

    Background

    Balloon tuboplasty is a therapeutic component of selective salpingography, a fluoroscopic tubal catheterization procedure that uses angiographic catheters to inject contrast directly into the fallopian tubes for diagnostic and sometimes therapeutic purposes. During selective salpingography the operator may attempt to re‑establish tubal patency by techniques such as contrast flushing, guidewire cannulation, or balloon tuboplasty, which involves tubal balloon catheterization targeted at a proximally occluded fallopian tube. Aetna’s policy limits coverage for balloon tuboplasty to the specific clinical scenario of infertility caused by proximal tubal occlusion demonstrated on hysterosalpingogram.

    Definitions

    Selective salpingography / fluoroscopic tubal catheterization — key facts
    DefinitionRadiologic procedure using an angiographic catheter to inject dye directly into the fallopian tubes for diagnostic and sometimes therapeutic purposes; may open occluded tubes without further manipulation.
    PurposeDiagnostic evaluation of tubal patency and potential therapeutic intervention to relieve proximal tubal obstruction.
    Techniques includedMay include flushing with contrast, selective dye injection, guidewire manipulation, and balloon tuboplasty as components of the procedure.
    Clinical effectivenessConsidered safe and effective for patients with proximal tubal occlusion demonstrated on hysterosalpingogram.
    AlternativesGuidewire fallopian tube recanalization or surgical treatment are alternative methods to manage tubal obstruction.
    Policy Summary
    PayerAetna
    PolicyTranscervical Balloon Tuboplasty
    Policy CodePolicy 0347
    Change TypeNo material changes
    Effective DateAug 27, 1999
    Last ReviewMay 30, 2023
    Next Review DateMar 28, 2024
    Key ActionObtain prior authorization when billing CPT 58345 and document proximal tubal occlusion on hysterosalpingogram with infertility diagnosis.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & BillingBackgroundDefinitions
    Note

    Alternatives Noted

    Alternatives to balloon tuboplasty should be considered and documented. These include selective salpingography techniques such as flushing with contrast media, guidewire recanalization, or surgical treatment of tubal obstruction.

    • Selective salpingography maneuvers: flushing with contrast, wire cannulation, or balloon tuboplasty.
    • Guidewire recanalization (fallopian tube recanalization).
    • Surgical treatment of tubal obstruction.
    Balloon tuboplasty (TBT) — key facts
    DefinitionTubal balloon catheterization performed during selective salpingography to attempt re-establishing patency of a proximally occluded fallopian tube.
    Role within selective salpingographyOne of several manipulations (after flushing or wire cannulation) that can be performed if initial dye injection does not open the tube.
    Indication supportedInvestigated as a therapeutic option for proximal tubal occlusion; part of approaches shown to be safe and effective when occlusion is demonstrated on hysterosalpingogram.
    Clinical contextUsed when selective dye injection and gentle wire manipulation are unsuccessful at restoring tubal patency.
    AlternativesGuidewire recanalization or surgical treatment may be considered if balloon tuboplasty is not successful or appropriate.