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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.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medical Necessity — Covered when ALL of the following are met:
Covered when ALL of the following are met:
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:
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
| 58345 | Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography. |
| 58340 | Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography. |
| 74740 | Hysterosalpingography, radiological supervision and interpretation. |
| 74742 | Transcervical catheterization of fallopian tube, radiological supervision and interpretation. |
| 76831 | Saline infusion sonohysterography (SIS), including color flow Doppler, when performed. |
| A9574 | Air polymer-type a intrauterine foam, 0.1 ml. |
| N97.1 | Female infertility of tubal origin |
Provider Actions & Billing
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.
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.
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.
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
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