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 and Investigational

    Transcervical balloon tuboplasty is considered experimental and investigational 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

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.

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. Binkovitz LA, King BF, Corfman RS. Advances in gynecologic imaging and intervention. May Clinic Proc. 1991;66:1133-1151.
  3. Confino E, Tur-Kasapa I, DeCherney A, et al. Transcervical balloon tuboplasty. A multicenter study. JAMA. 1990;264:2079-2082.
  4. 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.
  5. Kerin JF, Pearlstone AC, Williams DB, et al. Falloposcopic classification and treatment of fallopian tube lumen disease. Fertil Steril. 1992;57(4):731-741.
  6. National Institute for Clinical Excellence (NICE). Fallopian tube recanalisation by guidewire. Interventional Procedure Guidance 71. London, UK: NICE; 2004.
  7. National Institute for Clinical Excellence (NICE). Falloposcopy with coaxial catheter. Interventional Procedure Guidance 62. London, UK: NICE; 2004.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. Yoder IC, Hall DA. Hysterosalpingography in the 1990s. AJR. 1991;157:675-683.