Aetna considers transcervical balloon tuboplasty medically necessary for members with infertility due to a proximal tubal occlusion demonstrated on hysterosalpingogram.
Aetna considers transcervical balloon tuboplasty experimental and investigational for all other indications because its effectiveness for indications other than the one listed above has not been estalbished.
Balloon tuboplasty, one component of a selective salpingography procedure in which flushing with contrast media, wire cannulation or balloon tuboplasty can be used to relieve tubal obstruction, is safe and effective for patients with proximal tubal occlusion as demonstrated on hysterosalpingogram.
Fluoroscopic tubal catheterization (selective salpingography) using an angiographic catheter has been investigated both as a diagnostic technique modality and as a therapeutic modality. With selective salpingography, dye can be injected into the tubes more directly; occasionally this procedure is all that is needed to open the previously occluded fallopian tube. If this does not work, gentle manipulation with a wire is sometimes successful. Finally tubal balloon catheterization (TBT) has been investigated. Therefore, TBT is just one of several manipulations that can be performed at the time of a selective salpingography.
Alternative radiologic methods of clearing tubal obstruction include fallopian tube recanalization by guidewire (NICE, 2004). Tubal obstruction may also be treated surgically.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
58345
Other CPT codes related to this CPB:
58340
74740
74742
76831
ICD-9 codes covered if selection criteria are met:
628.2
Infertility, female, of tubal origin
The above policy is based on the following references:
Binkovitz LA, King BF, Corfman RS. Advances in gynecologic imaging and intervention. May Clinic Proc. 1991;66:1133-1151.
Confino E, Tur-Kasapa I, DeCherney A, et al. Transcervical balloon tuboplasty. A multicenter study. JAMA. 1990;264:2079-2082.
Yoder IC, Hall DA. Hysterosalpingography in the 1990s. AJR. 1991;157:675-683.
Kerin JF, Pearlstone AC, Williams DB, et al. Falloposcopic classification and treatment of fallopian tube lumen disease. Fertil Steril. 1992;57(4):731-741.
Gleicher N, Confino E, Corfman R, et al. The multicenter transcervical balloon tuboplasty study: Conclusions and comparison to alternative technologies. Human Reprod. 1993;8(8):1264-1271.
Woolcott R, Petchpud A, O'Donnell P, Stanger J. Differential impact on pregnancy rate of selective salpingography, tubal catheterization and wire-guide recanalization in the treatment of proximal Fallopian tube obstruction. Human Reprod. 1995;10(6):1423-1426.
Osada H, Kiyoshi Fujii T, et al. Outpatient evaluation and treatment of tubal obstruction with selective salpingography and balloon tuboplasty. Fertil Steril. 2000;73(5):1032-1036.
Papaioannou S, Afnan M, Girling AJ, et al. Long-term fertility prognosis following selective salpingography and tubal catheterization in women with proximal tubal blockage. Hum Reprod. 2002;17(9):2325-2330.
Aboulghar MA, Mansour RT, Serour GI, Al-Inany HG. Diagnosis and management of unexplained infertility: An update. Arch Gynecol Obstet. 2003;267(4):177-188.
Papaioannou S, Afnan M, Girling AJ, et al. Diagnostic and therapeutic value of selective salpingography and tubal catheterization in an unselected infertile population. Fertil Steril. 2003;79(3):613-617.
National Institute for Clinical Excellence (NICE). Fallopian tube recanalisation by guidewire. Interventional Procedure Guidance 71. London, UK: NICE; 2004.
National Institute for Clinical Excellence (NICE). Falloposcopy with coaxial catheter. Interventional Procedure Guidance 62. London, UK: NICE; 2004.
Papaioannou S, Afnan M, Sharif K. The role of selective salpingography and tubal catheterization in the management of the infertile couple. Curr Opin Obstet Gynecol. 2004;16(4):325-329.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
Close Window
