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.
See also CPB 0327 - Infertility.Background
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-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes covered if selection criteria are met:|
|58345||Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography|
|Other CPT codes related to this CPB:|
|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|
|ICD-10 codes covered if selection criteria are met:|
|N97.1||Female infertility of tubal origin|