58345
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.58
Facility
$255.18
Non-Facility
$255.18
Documentation Required
- Hysterosalpingogram (HSG) demonstrating proximal tubal occlusion (explicitly required by the stated covered indication: 'demonstrated on hysterosalpingogram').
- Clinical documentation supporting infertility due to tubal origin (e.g., diagnosis consistent with ICD-10 N97.1) and that the tubal occlusion is the clinical reason for attempting transcervical balloon tuboplasty.
- Documentation of the selected procedure code justification (e.g., use of CPT 58345) tying the service to the covered indication.
Key Coverage Criteria
- Transcervical balloon tuboplasty is medically necessary for members with infertility due to a proximal tubal occlusion demonstrated on hysterosalpingogram.
- ICD-10 code N97.1 (Female infertility of tubal origin) is listed as a covered diagnosis for this procedure.
- CPT 58345 (Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency) is covered if selection criteria are met (i.e., the indication above).
1 Active Policy
AETNA-CPB-0347 — Transcervical Balloon Tuboplasty
Related Codes
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