Transcervical Balloon Tuboplasty

Number: 0347

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses transcervical balloon tuboplasty.

  1. Medical Necessity

    Aetna considers transcervical balloon tuboplasty medically necessary for members with infertility due to a proximal tubal occlusion demonstrated on hysterosalpingogram.

  2. Experimental, Investigational, or Unproven

    Transcervical balloon tuboplasty is considered experimental, investigational, or unproven for all other indications because its effectiveness for indications other than the one listed above has not been established. 

  3. Related Policies

Table:

CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

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

Other HCPCS codes related to the CPB:
A9574 Air polymer-type a intrauterine foam, 0.1 ml

ICD-10 codes covered if selection criteria are met:
N97.1 Female infertility of tubal origin

Background

Transcervical balloon tuboplasty (TBT) is a minimally invasive, catheter‑based procedure intended to restore patency in selected women with proximal tube occlusion demonstrated on hysterosalpingogram (HSG). The procedure is typically performed under paracervical block or mild sedation, using a coaxial balloon catheter guided by fluoroscopy to mechanically dilate the uterotubal junction. TBT differs from other transcervical techniques, such as selective salpingography or hysteroscopic tubal cannulation, which primarily involve contrast injection or guidewire passage and may resolve functional obstruction related to tubal spasm, mucus, or debris rather than fixed luminal narrowing. TBT has been evaluated primarily in observational studies and multicenter cohort trials that demonstrate success in selected patients; however, reported pregnancy outcomes vary and are strongly influenced by underlying tubal pathology, including the presence of distal tubal disease or significant fibrosis. 

In current clinical practice, the use of TBT has declined relative to assisted reproductive technologies, reflecting changes in treatment paradigms rather than definitive comparative trial data. Although early prospective cohort studies demonstrated that TBT can restore tubal patency and result in pregnancy in selected women with isolated proximal tubal occlusion, no randomized trials have established superiority of balloon dilation over other transcervical approaches or over in vitro fertilization. Multiple techniques have been described for the management of proximal tubal occlusion, including selective salpingography with contrast flushing, fluoroscopic or ultrasound‑guided guidewire recanalization, hysteroscopic cannulation, and laparoscopic or microsurgical tubal procedures. These methods, including TBT, are variably employed based on patient selection, extent of tubal disease, and institutional expertise.

References

The above policy is based on the following references:

  1. 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.
  2. American Society for Reproductive Medicine (ASRM). Role of tubal surgery in the era of assisted reproductive technology: A committee opinion. Fertil Steril. 2021;115(5):1143-1150.
  3. Binkovitz LA, King BF, Corfman RS. Advances in gynecologic imaging and intervention. May Clinic Proc. 1991;66:1133-1151.
  4. Confino E, Tur-Kasapa I, DeCherney A, et al. Transcervical balloon tuboplasty. A multicenter study. JAMA. 1990;264:2079-2082.
  5. 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.
  6. Kerin JF, Pearlstone AC, Williams DB, et al. Falloposcopic classification and treatment of fallopian tube lumen disease. Fertil Steril. 1992;57(4):731-741.
  7. National Institute for Clinical Excellence (NICE). Fallopian tube recanalisation by guidewire. Interventional Procedure Guidance 71. London, UK: NICE; 2004.
  8. National Institute for Clinical Excellence (NICE). Falloposcopy with coaxial catheter. Interventional Procedure Guidance 62. London, UK: NICE; 2004.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. Roberts A. (2023). Fallopian tube recanalization for the management of infertility. CVIR endovascular, 6(1),13.
  14. 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.
  15. Yoder IC, Hall DA. Hysterosalpingography in the 1990s. AJR. 1991;157:675-683.